DISEASES 



INFANCY AND CHILDHOOD 



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HENRY C. LEA, Philadelphia. 



A TREATISE 



DISEASES 



INFANCY AND CHILDHOOD 



BY 



J. LEWIS SMITH, M.D., 

CLINICAL PROFESSOR OP DISEASES OF CHILDREN IN BELLEVUE HOSPITAL MEDICAL 

COLLEGE J PHYSICIAN TO THE NEW YORK FOUNDLING ASYLUM, AND TO THE 

NEW YORK INFANT ASYLUM J CONSULTING PHYSICIAN TO THE 

CHILDREN'S CLASS IN THE BUREAU FOR THE RELIEF 

OF THE OUT- DOOR POOR ; PHYSICIAN TO 

CHARITY HOSPITAL, ETC. ETC. 



FOUKTH EDITION, THOKOUGHLY BEVISED, 



WITH ILLUSTRATIONS. 



/ 



if 



v 




1 - ] ° 




/f> 18T9. &J 
OF V/jr v.^y" 



PHILADELPHIA 

HEKEY O. LE 

1879. 




10^? 



iS7f 



Entered according to Act of Congress, in the year 1879, by 

HENRY C. LEA, 

in the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER, 



PREFACE TO THE FOURTH EDITION. 



The last twenty-five years have witnessed marvellous progress, 
in our knowledge of the nature of children's diseases, and of their 
therapeutic requirements. The closer study of symptoms, the 
more general recording and publishing of clinical facts, and post- 
mortem appearances, the discussions in medical societies, which 
have awakened keen interest, the recent translation into our 
tongue of treatises, written by masters of the profession on the 
Continent, the activity of the medical journals, which immediately 
inform us of all valuable discoveries in medicine, whether at home 
or abroad, are some of the more conspicuous agencies which have 
effected so desirable a result. Of the ample material thus placed 
within reach, I have sedulously endeavored to make use. 

Since I was informed a year ago, that a fourth edition of this 
treatise would be called for, I have employed almost every leisure 
moment, which could be spared from necessary professional duties, 
in revising the text, and incorporating in it whatever was new and 
useful, so that it might fairly and fully represent the present state 
of our knowledge. I have therefore entirely rewritten several of 
the chapters, and have made corrections and additions on nearly 
every page ; yet, by the adoption of a somewhat closer type, these 
additions have been accommodated with but little increase in the 
bulk of the volume. 

During these late years the changes which have been made in 
the therapeutics of children's diseases are numerous. Depressing 
medicines have been for the most part laid aside, and those sub- 
stituted which fulfil the indications, while they sustain or do not 
reduce the strength. New and valuable medicines have been 
added to our pharmacopoeia, as the bromides, and hydrate of chlo- 



VI PREFACE. 

ral. Certain heretofore unknown or vaguely known effects of old 
remedies have been demonstrated and accepted, as of quinine and 
digitalis, so that these are used for purposes for which, till recently, 
more depressing, and therefore objectionable agents, were employed. 
Moreover, the need felt of making prescriptions for children as 
little nauseous as possible — stimulated to a certain extent by the 
fact that a system has spread through the community, whose one. 
merit was that the medicines which it employed were readily 
taken by the youngest child — has led to many changes in the 
form of the remedies employed, and in the modes of prescribing. 
Aiding in this object, of rendering medicines palatable for chil- 
dren, pharmaceutical chemistry has in these recent times furnished 
many preparations, which are much more readily administered 
than the cruder and more bulky substances formerly employed. 
In view of these changes in our materia medica I have found it 
necessary to rewrite a large proportion of the prescriptions con- 
tained in the text, nearly all of which have been sufficiently tested 
either in my private practice, or in the institutions with which I 
have an official connection. 

I esteem it a very great privilege, and one which greatly en- 
hances the value of this book, that I am connected with three of 
the large charities of New York in which children are treated, 
and which afford unsurpassed opportunities for observation. In 
one of these- about 8000 children are treated annually. To the 
Sisters, and my colleagues of the 1ST. Y. Foundling Asylum, to 
Dr. Angell of the K Y. Infant Asylum, and to my colleagues in 
the Bureau for the Relief of the Out-Door Poor, I am under 
many obligations for their generous and earnest co-operation in 
the study of such cases as demanded minute and daily examina- 
tions. 

No. 227 W. Forty-ninth Street, N. Y. 
February, 1879. 



CONTENTS. 



PART I. 

CHAPTER I. 

PAUE 

Infancy and Childhood 17 

CHAPTER II. 

Cake of the Mother in Pregnancy . . . . . .19 

CHAPTER III. 
Mortality of Early Life — its Causes and Prevention . . 24 

CHAPTER IY. 

Lactation 29 

Hindrances to Lactation, and physical conditions rendering it Improper 
— Facts and Rules in reference to Lactation — Human Milk — Modifica- 
tion of the Milk in consequence of the Diet — Modification of Milk from 
its retention in the Breast — Modification of Milk by Age and by Men- 
tal Impressions — Modification of Milk by the Catamenial Function and 
Pregnancy — Quantity of Breast-milk required by the Infant — Differ- 
ences in Suckling Women as regards Quantity and Quality of Milk — 
Scantiness of Milk ; its Causes and Treatment. 

' CHAPTER V. 
Selection of a Wet-Nurse 49 

CHAPTER VI. 
Course of Lactation — Weaning ....... 52 

CHAPTER VII. 

Artificial Feeding 55 

Composition of Milk. 

CHAPTER VIII. 
Baths — Clothing GO 



Vlll CONTENTS. 



CHAPTER IX. 

PAGE 

Accidents and Ailments incidental to the birth of the Infant, 
and Detachment of the Cord ....... G2 

Apncea (Asphyxia) Neonatorum — Causes — Treatment — Caput Succe- 
daneum — Cephalsematoma. 

CHAPTER X. 

Ophthalmia Neonatorum G5 

Causes — Symptoms — Treatment. 

CHAPTER XL 

Diseases of the Umbilicus 69 

Inflammation of the Umbilical Vein and Arteries — Treatment — In- 
flammation and Ulceration of Umbilicus — Treatment — Umbilical 
Granulations or Fungus — Treatment. 

CHAPTER XII. 
Umbilical Hemorrhage 71 

Sex — Age — Causes — Symptoms — Prognosis — Treatment. 

CHAPTER XIII. 

Diagnosis of Infantile Diseases 75 

General Observations — Features, External Appearance of Head, 
Trunk, and Limbs in Disease — Attitude — Movements — The Voice — 
Respiratory System — Respiration in Health — Respiration in Disease — 
Circulatory System — Pulse in Health — Pulse in Disease — Animal 
Heat — Digestive System, Pain. 

CHAPTER XIV. 
Therapeutics . . .87 



PAET II. 

CONSTITUTIONAL DISEASES. 

SECTION I. 
DIATHETIC DISEASES. 

CHAPTER I. 

Rachitis 89 

Age — Causes— Anatomical Characters : First Stage ; Second Stage ; 
Craniotabes ; Third Stage — Symptoms— Complications- — Diagnosis — 
Prognosis — Treatment. 



CONTEXTS. IX 



CHAPTER II. 

PAGE 

Scrofula 102 

Causes — Anatomical Characters — Symptoms — Relation of Serofulosis 

to Tuberculosis — Prognosis — Treatment : Prophylactic ; Curative. 

CHAPTER III. 

Tuberculosis 120 

Etiology — General Anatomical Characters of Tuberculosis — Anato- 
mical Characters in Infancy and Childhood — Lungs — Abdominal Vis- 
cera — Stomach and Intestines — Symptoms — Encephalon — Bronchial 
Glands — Physical Signs — Lungs — Pleura — Stomach and Intestines — 
Diagnosis — Prognosis — Treatment : Prophylactic ; Curative. 

CHAPTER IV. 

Syphilis 143 

Etiology — Clinical History — Goryza — Mucous Patches —Roseola — 
Pemphigus — Acne, Impetigo, and Ecthyma — Visceral Lesions — Os- 
seous Lesions — Prognosis — Treatment. 

SECTIOX II. 
ERUPTIVE FEVERS. 

CHAPTER I. 

MEASLES 154 

Symptoms — Complications — Anatomical Characters — Nature — Diag- 
nosis — Prognosis — Treatment. 

CHAPTER II. 
Scarlet Fever 163 

Symptoms : Regular Form ; Irregular Form ; Malignant Form — 
Complications — A Case — Sequela? — Otitis — Anatomical Characters — 
Nature — Diagnosis — Prognosis — Treatment — Prophylaxis — Care of 
Patients — Infected Articles. 

CHAPTER III. 
Rothelx . . . . . . . . . . . .191 

Premonitory Stage — Symptoms — Tegumentary System — Skin — Mu- 
cous Membrane — Pulse — Temperature— Respiratory System — Diges- 
tive System — Complications — Prognosis — Nature. 

CHAPTER IV. 

Variola — Varioloid 198 

Incubative Period — Stage of Invasion — Stage of Eruption — Stage of 
Desiccation — Varioloid — Mode of Death — Anatomical Characters — 
Complications — Prognosis — Diagnosis — Treatment. 



X CONTENTS. 



CHAPTER V. 

PAGE 

Vaccinia . . .' . . . 208 

Appearances — Symptoms — Anomalies, Complications, and Sequels — 
Subsequent Vaccinations — Protection from Vaccination — Revaccina- 
nation — Selection of Virus. 

CHAPTER VI. 

Varicella 218 

Symptoms — Diagnosis — Prognosis — Treatment. 

SECTION III. 
NON-ERUPTIVE CONTAGIOUS DISEASES. 

CHAPTER I. 

Diphtheria 221 

Age — Incubation — Nature — Cases — Anatomical Characters — Cases — 
Symptoms — Diagnosis — Prognosis — Treatment — General Treatment 
— Stimulants — Local Treatment — Diphtheritic Croup — ■ Preventive 
Measures. 

Pertussis 264 

Age — Causes — Pathological Anatomy — Symptoms — Second Period — 
Complications — Diagnosis — Prognosis — Treatment — Prophylaxis. 

CHAPTER II. 

Parotiditis . ... . . . . . . . . 278 

Nature — Diagnosis — Treatment. 

SECTION IV. 
OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever ... 281 

Sy m ptoms — Treatm ent . 

CHAPTER II. 

Remittent Fever . . . 286 

Symptoms — Diagnosis— Treatment. 

CHAPTER III. 

Typhoid Fever 288 

Causes — Anatomical Characters — Symptoms — Complications — Diag- 
nosis — Duration — Prognosis — Treatment. 



CONTENTS. XI 



CHAPTER IV. 

PAGE 

Cerebro-Spixal Fever 295 

Cause — Sex — Age — Symptoms— Alodeof Commencement — Symptom? 
pertaining to the Nervous System — Digestive System — Pulse — Tem- 
perature — Respiratory System — Cutaneous Surface — N ature — Prog- 
nosis — Diagnosis — Anatomical Characters — Treatment : Preventive ; 
Curative. 

CHAPTER V. 

Acute Rheumatism 326 

Causes — Symptoms — Duration — Prognosis — Diagnosis— Treatment. 

CHAPTER VI. 

Erysipelas 332 

Table of Cases — Age — Point of Commencement — Causes — Premoni- 
tory Symptoms — Symptoms — Prognosis — Duration — Modes of Death 
— Pathological Anatomv — Treatment. 



PAET III. 

SECTION I. 
DISEASES OF THE CE REBRO-SPINAL SYSTEM. 

CHAPTER I. 

Acephalus — Axexcephalus . . . . . . . .343 

Anatomical Characters? — Symptoms — Prognosis. 

CHAPTER II. 

Imperfect Braix 345 

Case — Symptoms — Prognosis — Alicrocephalus — Atrophy of Brain. 

CHAPTER III. 

Hypertrophy of Braix ......... 348 

Pathological Anatomy — Causes — Symptoms — Cases — Diagnosis — 
Prognosis — Treatment. 

CHAPTER IV. 

Thrombosis ix the Craxial Sixuses (Phlebitis) .... 354 
Anatomical Characters — Causes — Symptoms — Diagnosis — Prognosis — 
Treatment. 



Xll CONTENTS 



CHAPTER V. 

PAGE 

Congestion of the Brain . . . . . . . . . 358 

Causes — Symptoms — Anatomical Characters — Prognosis — Treatment. 

CHAPTER VI. 

Intra-Cranial Hemorrhage (Meningeal Hemorrage — Cerebral 
Hemorrhage) . . . 363 

Causes — Anatomical Characters — Cerebral Hemorrhage — Symptoms — 
Diagnosis — Prognosis — Treatment. 

CHAPTER VII. 

Congenital Hydrocephalus . . . . . . . .373 

Anatomical Characters — Symptoms — Diagnosis — Prognosis— Treatment. 

CHAPTER VIII. 

Acquired Hydrocephalus . . . 380 

Causes — Anatomical Characters — Symptoms — Prognosis — Treatment. 

CHAPTER IX. 

Meningitis, Simple and Tubercular 383 

Age — Pathological Anatomy — Causes — Premonitory Stage — Symp- 
toms — A Case — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Spurious Hydrocephalus 402 

Anatomical Characters — A Case — Symptoms — Cases — Diagnosis — 
Prognosis — Treatment. 

CHAPTER XL 

Eclampsia 407 

Causes — Premonitory Stage — Symptoms — Anatomical Characters — 
Diagnosis — Prognosis — Treatment. 

CHAPTER XII. 

Tetanus Infantum . • .417 

Fatal Cases— Favorable Cases — Period of Commencement — Frequency 
in Certain Localities — Causes — Symptoms — Mode of Death — Prognosis 
— Duration in Fatal Cases — Duration in Favorable Cases — Diagnosis — 
Preventive Treatment — Treatment. 

CHAPTER XIII. 

Internal Convulsions . .437 

Causes — Anatomical Characters — Symptoms — A Case — Diagnosis — 
Prognosis — Modes of Death — Treatment. 



CONTENTS. Xlll 



CHAPTER XIV. 

PAGE 

Chorea 44G 

Age — Causes — Sex — Uterine Irritation — Anasmia — Rheumatism — Mi- 
croscopic Appearances : Spinal Cord ; The Heart ; The Lungs — Fright 
Imitation — Intestinal Irritation — Lesions of Brain and Spinal Cord — 
Anatomical Characters — Symptoms — Prognosis — Course — Diagnosis — 
Treatment : Regimenal ; Medicinal. 

CHAPTER XV. 

Infantile Paralysis 462 

Symptoms — Groups — Single Muscles — Prognosis — Progress — Etiology 
■ — Anatomical Characters — Diagnosis — Prognosis — Treatment. 

CHAPTER XVI. 

Facial Paralysis 473 

Causes — Symptoms — Prognosis — Treatment — Paralysis with Pseudo- 
H y pertrophy — Anatomical Characters — Causes — Prognosis — Treat- 
ment. 

CHAPTER XVII. 

Diseases of the Spinal Cord and its Coverings . . . .4 79 
Congestion of the Spinal Cord and its Membranes — Anatomical Char- 
acters — Symptoms — Treatment. 

CHAPTER XVIII. 

Spina Bifida 483 

Diagnosis — Prognosis — Treatment. 

CHAPTER XIX. 

Vertebral Caries 487 

Causes — Symptoms — Diagnosis — Prognosis — Treatment. 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 

CHAPTER I. 

CORYZA 492 

Anatomical Characters — Symptoms — Prognosis — Treatment. 

CHAPTER II. 

Catarrhal Laryngitis ......... 495 

Symptoms — Anatomical Characters — Treatment — Spasmodic Laryn- 
gitis — Causes — Symptoms — Anatomical Characters — Pathology — Diag- 
nosis — Treatment. 



XIV CONTENTS. 



CHAPTER III. 

PAGE 

Pseudo-membranous Laryngitis 504 

Causes — Anatomical Characters — Symptoms — Pathological Characters 
— Diagnosis — Prognosis — Treatment. 

CHAPTER IV. 

Bronchitis 518 

Causes — Anatomical Characters — Symptoms — Diagnosis — Prognosis — 
Treatment. 

CHAPTER V. 

Atelectasis 530 

Acquired Atelectasis — Symptoms — Anatomical Characters — Treat- 
ment. 

CHAPTER VI. 

Pneumonitis 534 

Catarrhal, Croupous, and Interstitial — Causes — Anatomical Characters 
— Cheesy Pneumonitis — Symptoms — Physical Signs — Diagnosis — 
Treatment. 

CHAPTER VII. 

Pleuritis 549 

Cause — Cases — Anatomical Characters — Symptoms — Physical Signs — 
Auscultation — Percussion — Inspection — Mensuration — A Case — Diag- 
nosis — Prognosis — Treatment — Nervous Cough — Treatment. 



SECTION III. 
DISEASES OF THE DIGESTIVE APPARATUS. 

CHAPTER I. 

Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis 573 
Simple or Catarrhal Stomatitis — Causes — Symptoms — Appearances — 
Treatment — Ulcerous Stomatitis — Causes — Symptoms — Prognosis — 
Treatment — Aphthous Stomatitis — Causes — Symptoms — Diagnosis — 
Prognosis — Treatment. 

CHAPTER II. 

Thrush .579 

Anatomical Characters — Symptoms — Causes — Diagnosis — Prognosis — 
Treatment. 

CHAPTER III. 

Gangrene of the Mouth , . 584 

Anatomical Characters — Age — Causes — Symptoms — Diagnosis — Prog- 
nosis — Treatment. 



CONTENTS. XV 



CHAPTER IV. 

PAGE 

Dentition . . . . . . . . . . . .591 

Pathological Results of Dentition — Diagnosis — Treatment — Second 
Dentition. 

CHAPTER V. 

Catarrhal Pharyngitis, Peri-pharyngeal Abscess, CEsophagitis, 599 
Anatomical Characters — Causes — Symptoms — Prognosis — Diagnosis — 
Treatment — Peri-Pharyngeal Abscess — Age — Cause — Anatomical Cha- 
racters — Symptoms — Diagnosis — Prognosis - — Treatment — CEsopha- 
gitis — Anatomical Characters — Treatment. 

CHAPTER VI. 

Indigestion, Congestion of Stomach, Gastritis, Follicular Gas- 
tritis, Diphtheritic Gastritis, Post-mortem Digestion, Soft- 
ening 609 

Causes — Symptoms — Prognosis — Treatment — Congestion of the Sto- 
mach — Gastritis — Cause — Age — A Case — Symptoms — Anatomical 
Characters — Diagnosis — Prognosis — Treatment — Follicular Gastritis — 
Diphtheritic Gastritis — Post-mortem Digestion, Softening — A Case. 

CHAPTER VII. 

DlARRHCEA . . . . . ... . . . . .625 

X on-Inflammatory Diarrhoea — Causes — Symptoms — Anatomical Cha- 
racters — Prognosis — Treatment. 

CHAPTER VIII. 

Intestinal Catarrh of Infancy 630 

Causes — Age — Symptoms — Anatomical Characters — Diagnosis — Prog- 
nosis — Treatment : Regimenal Measures ; Medicinal Treatment ; Ene- 
mata ; External Treatment. 

CHAPTER IX. 

Enteritis and Colitis in Childhood ...... 653 

Causes — Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Cholera Infantum .......... 656 

Causes — Symptoms — Anatomical Characters — Nature — Diagnosis — 
Prognosis — Treatment. 

CHAPTER XL 

Intestinal Worms 664 

Ascaris Lumbricoides — Oxyuris Vermicularis — Taenia — Bothriocepha- 
lus — Trichocephalus dispar — Causes — Symptoms — Diagnosis — Prog- 
nosis — Treatment. 



XVI CONTENTS 



CHAPTER XII. 

PAGE 

Gastro-Intestinal Hemorrhage ....... 68*2 

Three Varieties — A Case — Prognosis — Treatment. 

CHAPTER XIII. 

Intussusception . . . 687 

Intussusception without Symptoms — Intussusception with Symptoms — 
Previous Health — Causes — Age — Seat and Pathological Anatomy — In- 
tussusception in the Small Intestine — Cases — Intussusception in Large 
Intestines — Sy mptoms — Diagnosis — Duration — Prognosis — Modes of 
D eath — Treatment. 



SECTION IV. 
DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

Cyanosis 712 

Literature of Cyanosis — Sex — Causes of the Malformations — Time of 
Commencement — Symptoms — Prognosis — Mode of Death — Modes of 
Compensation — Morbid Anatomy — Theories Relating to the Etiology 
of Cyanosis — Treatment. 

SECTION V. 
SKIN DISEASES. 

CHAPTER I. 

Erythematous Diseases 730 

Erythema : Two Forms ; Idiopathic, Symptomatic — Prognosis — Diag- 
nosis — Treatment. Roseola : Symptoms— Causes — Prognosis — Diag- 
nosis — Treatment. Urticaria : Causes — Prognosis — Diagnosis — Treat- 
ment. 

CHAPTER II. 

Papular Diseases, Strophulus ........ 736 

Treatment. 

CHAPTER III. 

Eczema 738 

Anatomy — Etiology — Varieties — Symptoms — Course — Diagnosis — 
Treatment — Local Treatment — Scabies : Diagnosis — Treatment. 

Index 749 



THE 



DISEASES OF CHILDREN 



PAET I 



CHAPTER I. 

INFANCY AND CHILDHOOD. 

Infancy and childhood are in certain respects the most important and 
interesting periods of life. To the physiologist they are especially inter- 
esting, because they are the periods of development and of greatest func- 
tional activity ; to the pathologist, because in them many diseases occur 
which are rarely or never observed in the other periods, or which present 
in these periods peculiar features ; to the physician and vital statistician, 
because in them there is the greatest amount of sickness, and largest 
number of deaths. 

Infancy extends from birth to the age of two and a half years, or till 
the completion of first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily 
injured. In this period the brain is rapidly developed — more so than any 
other organ ; animal matter predominates in the bones ; the arteries are 
relatively large, the muscles small ; the superficial veins are small. Fat 
is absent from the interior of the body, but abundant, in well-nourished 
infants, underneath the integument. The skin is delicate, and its temper- 
ature not much below that of the blood. At birth it has a reddish hue, 
and is covered with soft fine hairs (lanugo). The reddish hue gradually 
fades into the healthy tint of infancy, and the hairs fall out. In the first 
two months the sweat-glands have little functional activity, sensible per- 
spiration being quite rare. Subsequently perspiration is freer, and in 
certain diseased states (rachitis, etc.) is abundant. The sebaceous glands 
in the first half of infancy are active, particularly upon the scalp, pro- 
ducing often a pale yellow incrustation, consisting of sebaceous matter 
and epidermic cells. 

The secretions from, the mucous surfaces commence at an early period. 
At birth the surface of the digestive tube is covered with more or less 



18 INFANCY AND CHILDHOOD. 

mucus, often in considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat epi- 
thelial cells, fine hairs, oil-globules, crystals of cholesterin, and brownish 
or yellowish masses of coloring matter, probably from the liver. It is 
supposed that, with the exception of the coloring matter, the meconium is 
derived mainly from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, through 
the exigencies of the new life, is that in the circulation. The flow of blood 
being interrupted, thrombi form in the umbilical vein, and arteries, and 
in the ductus arteriosus, and ductus venosus, and these vessels gradually 
atrophy, becoming finally shrivelled but permanent cords. I have many 
times at autopsies removed the plug from the ductus arteriosus when death 
had occurred as late as the third week. The foramen ovale closes slowly. 
I have ordinarily found it open till near the end of the first half year, but 
the valve closes fully the aperture, so that there is no detriment to the 
circulation. Both the pulse and respiration are more frequent during 
infancy than childhood, and are more readily accelerated by moral and 
physical causes. 

The stomach is less elongated and emesis more readily produced than 
in the adult. The liver is large, occupying at birth nearly half of the 
abdominal cavity, but it grows smaller in successive months. The appe- 
tite is good and digestion active, so that hunger, when appeased, soon re- 
turns. The thymus gland, at birth about the size of an unexpanded lung, 
slowly atrophies, but it does not totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their form, 
so as to present in the last part of infancy nearly the shape of the organ 
in the adult. The renal secretion commences early, even before birth. 
The kidneys seldom undergo degenerative changes as in the adult, but 
they are liable to congestions and inflammations. During the first month, 
and especially the first fortnight, crystals of uric acid, and the urates, are 
often found in the urine, in a state of apparent health, causing more or 
less fretfulness in their elimination, staining the diaper, and not infre- 
quently being arrested in the tubules of the pyramids, where they can be 
seen as pink-colored spots or lines (uric acid infarction). These deposits 
of uric acid and the urates may even occur in the fcetus, producing ob- 
struction and inflammation of the renal tubes. Congenital cystic degen- 
eration of the kidneys is, in the opinion of Virchow, due to them. In 
early infancy the senses are imperfectly developed, the eyes being at- 
tracted only by bright objects, and the sense of hearing affected only by 
loud noises. Sleep is the normal state in the first weeks of life ; as the 
age of the infant increases, less and less sleep is required ; but the oldest 
infants need more than children, and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. It 
seeks the breast by instinct, and it exhibits no perception or reflection. 



CAKE OF THE MOTHER IN PREGNANCY. 19 

The loud cries with which it commences its existence are not from anger 
or suffering ; they appear to be normal, like the act of nursing, and provi- 
dentially designed in order to expand the lungs. It is not till the close, 
or near the close, of the first month, that the gray substance of the brain 
begins to appear — the probable seat of the mind, and the source of all 
mental phenomena. Perception and curiosity are early manifested. The 
infant, as Edmund Burke has remarked, is constantly seeking new objects 
for its amusement, rejecting old playthings for such as possess more 
novelty. Reflection, a higher faculty of the mind, appears at a later 
period. The mind and the bodily organs in infancy are, in a high degree, 
impressionable. Anger is excited by trivial causes, but is easily appeased ; 
and the various functions in the system are disturbed by agencies which 
in youth or manhood would have no appreciable effect. 

Childhood extends from infancy to the age of fifteen years or puberty. 
It is a period of great physical activity, and of rapid growth. The func- 
tions of the various organs are performed with more moderation than in 
infancy, and are less frequently deranged. The volume of the brain con- 
tinues to increase rapidly, and it becomes firmer than in infancy. It is 
estimated that by the seventh year the weight of this organ has doubled. 
The mind now exerts a controlling influence over the actions of the indi- 
vidual. The digestive organs have changed, so that solid food is required. 
Most of the glandular organs are less active than in the greater part of 
infancy, and some of them, as the liver, are relatively smaller. The 
pulse and respiration gradually become less frequent as the child advances 



CHAPTER II. 

CARE OF THE MOTHER IN PREGNANCY. 

The frequency of miscarriages and still-births, and the large number 
of ill-formed and puny infants, born to a precarious and short existence, 
render imperative, on the part of the mother, a strict observance of the 
laws of health, and an avoidance of all exciting or perturbating influ- 
ences during the time when the fetus is being developed. The diet should 
be plain and easily digested, but nutritious. There is often a craving in 
pregnancy for unusual articles of food. These may sometimes be allowed 
within certain limits, provided that they are such as do not derange the 
stomach. Meats and animal broths, together with vegetables and fari- 
naceous food, should constitute the ordinary diet, and should be taken at 
regular intervals. 

Daily exercise, never violent, but moderate and gentle, is requisite. 2so 



20 CAEE OF THE MOTHER IN PREGNANCY. 

exercise is better, none safer and more likely to contribute to cheerfulness 
and healthy functional activity of the organs, than the ordinary household 
duties. Lifting heavy weights, or work which,' like washing and ironing, 
causes great and continued action of the abdominal muscles, should be 
avoided. Such exercise is highly injurious, and is apt to produce prema- 
ture labor. Exercise in the open air, on foot, or by an easy conveyance, 
conduces to the health of the mother and the growth and development of 
the foetus. On the other hand, rapid riding over rough roads is one of the 
most dangerous modes of exercise. It has been known to destroy the 
foetus, which up to that time had been apparently vigorous. When such 
a result occurs, there is probably more or less detachment of the placenta. 

It being a matter of the utmost importance that the health of the mother 
should continue good during gestation, any disease which she may have in 
this period, and which affects her nutrition or the character of her blood, 
should be promptly cured if practicable, and with the least possible reduc- 
tion of the vital powers. Intermittent fever, occurring during gestation, 
should never be allowed to continue. It seriously retards foetal develop- 
ment, and may produce miscarriage. Unless it is controlled by proper 
measures, the offspring, though born at term, is puny and emaciated. 
Syphilis, in the pregnant woman, also requires treatment. This disease, 
readily transmitted from the mother to the foetus through the ovum or the 
uterine circulation, may be eradicated by anti-syphilitic treatment of the 
mother, or at least so modified that the infant is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical 
exertion. There is, during pregnancy, unusual susceptibility to mental 
impressions, and this should be borne in mind not only by the woman 
herself, but by those who associate with her. 

Strong emotions, whether of joy, sorrow, or anger, affect primarily the 
nervous system, but indirectly most of the organs of the body. Observa- 
tions have long established the fact, that such emotions influence the state 
and functions not only of the digestive and glandular, but muscular organs, 
as the heart and uterus. Physicians are familiar with cases in which 
vivid mental impressions produced uterine contractions, and even mis- 
carriage, or have disturbed the catamenial function. Therefore, the 
associations and cares of pregnant women should be such as conduce to 
cheerfulness and equanimity. 

It is the popular belief, and the belief of many physicians, that vivid 
mental impressions sometimes have a direct effect on the development of 
the foetus. Many cases are on record in which infants were born with 
marks or deformities, corresponding in character with objects which had 
been seen and had made a strong impression on the maternal mind at some 
period of gestation. Whether the mind of the mother exerts a control- 
ling influence on the form and color of the foetus, is a subject of great 



MATERNAL IMPRESSIONS. 21 

interest to the psychologist as well as physiologist and physician, since it 
involves no less a question than the power and scope of the human mind. 
Violent emotions, it is admitted, may affect directly most of the important 
organs in the system. They may derange the liver, causing jaundice, 
accelerate, or for a moment suspend, the heart's action, stimulate the kid- 
neys, causing diuresis, or even the intestinal follicles, causing watery 
evacuations. But with all these organs the brain is connected by nerves 
which anatomy reveals. On the other hand, the mother and foetus have 
a distinct existence as regards their nervous systems, and even their blood. 
Still, the multitude of facts which have accumulated justify the belief 
that deformity or other abnormal development of the foetus is, sometimes, 
clue to the emotions of the mother. Some of the cases related by Dr. 
Whitehead, in his work on hereditary diseases, are very striking and dif- 
ficult to explain on the ground of coincidence. I have met the following 
cases. An Irish woman of strong emotions and superstitions was passing 
along a street in the first months of her gestation, when she was accosted 
by a beggar, who raised her hand, destitute of thumb and fingers, and in 
" God's name" asked for alms. The woman passed on ; but reflecting in 
whose name money was asked, felt that she had committed a great sin in 
refusing assistance. She returned to the place where she had met the 
beggar, and on different days, but never afterwards saw her. Harassed 
by the thought of her imaginary sin, so that for weeks, according to her 
statement, she was made wretched by it, she approached her confinement. 
A female infant was born, otherwise perfect, but lacking the fingers and 
thumb of one hand. The deformed limb was on the same side, and it 
seemed to the mother to resemble precisely that of the beggar. In another 
case which I met, a very similar malformation was attributed by the 
mother of the child to an accident occurring to a near relative, which 
necessitated amputation during the time of her gestation. I examined 
both of these children with defective limbs, and have no doubt of the 
truthfulness of the parents. In May, 1868, I removed a supernumerary 
thumb from an infant, whose mother, a baker's wife, gave me the following 
history : No one of the family, and no ancestor, to her knowledge, pre- 
sented this deformity. In the early months of her gestation she sold 
bread from the counter, and nearly every day a child with double thumb 
came in for a penny roll, presenting the penny between the thumb and the 
finger. After the third month she left the bakery, but the malformation 
was so impressed upon her mind, that she was not surprised to see it repro- 
duced in her infant. 

Professor William A. Hammond, of this city, in an interesting paper 
on the "Influence of the Maternal Mind," etc. {Quarterly Journal of 
Psychological Medicine, January, 1868), says : " The chances of these 
instances, and others which I have mentioned, being due to coincidence, 
are infinitesimally small, «and though I am careful not to reason upon the 



22 CAEE OF THE MOTHER IN PREGNANCY. 

principle of post hoc, ergo propter hoc, I cannot, nor do I think any 
other person can, no matter how logical may be his mind, reason fairly 
against the connection of cause and effect in such cases. The correctness 
of the facts can only be questioned ; if these be accepted, the probabilities 
are thousands of millions to one, that the relation between the phenomena 
is direct." Professor Dalton also says (Human Physiology), " There is 
now little room for doubt that various deformities and deficiencies of the 
foetus, conformably to the popular belief, do really originate in certain 
cases from nervous impressions, such as disgust, fear, or anger, experienced 
by the mother." The observations on which this belief is based relate 
both to man and the lower animals. A very strong argument in its sup- 
port is, as Professor Hammond remarks, the popular opinion, which dates 
back to the time of Jacob (Genesis xxx). An almost universal sentiment, 
running through centuries, is rarely wholly fallacious. It has some truth 
for its foundation, especially when, as in this instance, the subject is one 
of observation. 

If maternal emotions affect the development of the exterior of the 
foetus, as observations show, and physiologists admit, the presumption is 
strong that they may affect also the proper development and adjustment 
of the parts of the brain, an organ so complex and delicate, and may 
therefore give rise to idiocy. Dr. Seguin (Idiocy and its Treatment, etc., 
New York, 1866) thus remarks on this point : " Impressions will, some- 
times, reach the foetus, in its recess, cut off its legs or arms, or inflict large 
flesh wounds, before birth, . . . from which we surmise that idiocy holds 
unknown though certain relations to maternal impressions, as modifica- 
tions to placental nutrition." 

And it is an interesting fact that abnormalities of structure, occurring 
from whatever cause, are apt to be propagated to descendants. Dr. Car- 
penter and others relate instances among the lower animals, and similar 
instances of transmission have now and then been observed in the human 
race. Thus, in the issue of Nature for March 7th, 1878, it is stated on 
the authority of M. Lenglen, a physician of Arras, that a certain M. 
Gamelon in the last century had two great thumbs on each hand, and 
two great toes on each foot ; this peculiarity did not appear in the son, 
but it reappeared in the three succeeding generations, so that some of the 
great-great-grandchildren possessed it in as marked a degree as their 
ancestors. 

In view of such important facts, the duty of the pregnant woman is 
rendered the more imperative to avoid the presence of disagreeable and 
unsightly objects, as well as all causes of excitement, and to remove, as 
soon as possible, vivid and unpleasant impressions, by quiet diversion of 
the mind. 

The disastrous results upon the foetus of severe injuries received by the 
mother are well know to the profession, for premature labor and death of 
the child, or feebleness from its prematurity, are common results of such 



MATERNAL INJURIES. 



23 



Fie*. 1. 




accidents. In rare instances the child may be so injured as to be deformed 
for life, as in the following inter- 
esting case : Richard L., aged six 
years, came, in January, 1877, to 
the children's class in the Bureau 
for the relief of the Out-Door 
Poor. The following history was 
obtained: On November 27th, 
1870, one month before the birth 
of Richard, the mother fell heavily 
on the ice when stepping from 
a city car. Uterine hemorrhage 
resulted, which continued more 
or less freely, producing marked 
pallor till her confinement, which 
occurred December 23d. The 
position of the child in utero was 
crosswise, but nothing untoward 
occurred in the delivery. Imme- 



diately after its birth, when it 
was being w r ashed by the nurse, 
a blister, about one inch in diame- 
ter, was observed on the right side of the thorax, located about one 
inch below and two and a half inches externally to the nipple. A 
cicatrix resulted which now marks the site of the sore. When the blister 
healed, the child seemed entirely well, and nothing more was thought of 
the unusual occurrence of an intra-uterine vesication, till nearly half a 
year had elapsed, when the thorax below the nipple and at the site of the 
cicatrix was observed to be depressed, an,d the depression has continued 
to the extent indicated in the wood-cut. 

The ribs at the point of depression are found to be widely separated ; 
the rib below being pushed downward so as to form one side of the tri- 
angle, its cartilage the second side, and the rib above the hypothenuse. 
The distance of the perpendicular line passing from the costo-chondral 
articulation of the lower rib to the upper rib, or the hypothenuse, is two 
and a half inches by measurement. The depression in this triangular 
space evidently resulted gradually from the wide separation of the ribs, 
and the consequent loss of resiliency in the thoracic walls in the space 
destitute of bony support. The child lay crosswise in utero, and it seems 
probable that the injury was produced by the pressure of its arm against 
the ribs during the fall. Cases like the above, and the graver cases in 
which foetal life is sacrificed, or the child is born to a puny and uncertain 
existence from prematurity, show the very great importance of a quiet 
and regular life on the part of one who is about to become a mother ; for 
bodily injuries, like unpleasant sights, occur when least expected. 



24 MORTALITY OF EARLY LIFE, 



CHAPTER III. 

MORTALITY OF EARLY LIFE : ITS CAUSES AND PREVENTION. 

No fact is better known in the profession, than that the first years of 
life constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and deaths, 
statistics show fifteen deaths in every hundred infants in the first year of 
life, and between four and five deaths in the first month. Statistics on the 
continent correspond with those in England, as regards the periods of 
greatest mortality. Quetelet says :...." There die during the first 
month after birth, four times as many children as during the second month 
after birth, and almost as many as during the entirety of the two years that 
follow the first year, although even then the mortality is high. The tables 
of mortality prove, in fact, that one-tenth of children born die before the 
first month has been completed." 

In this country, in consequence of deficient registration of births, the 
percentage of deaths to births cannot be accurately ascertained. In this 
city, 53 per cent, of the total number of deaths occur under the age of five 
years, and 26 per cent, under the age of one year. According to the census 
of 1865, there were in New York City 95,020 children under the age of five 
years, and during the five years ending with 1865, 49,000 children five 
years old and under had died. Therefore, according to these statistics, 
more than one-third of all the infants born in this city die under the age 
of five years. An error, however, occurs from the fact that, while the 
death statistics were complete, it is known there were more children in the 
city than were embraced in the census returns. Still it may, I think, be 
safely stated that one-fourth of the children born in this city die before the 
age of five years. 

In less crowded cities and the rural districts, it is known that the per- 
centage of deaths in the first years of life to the total number of deaths is 
considerably less than in New York City, but it is nevertheless large. 

As the child advances towards puberty, the liability to sickness and 
death gradually diminishes, but even the last years of childhood present a 
considerably larger percentage of deaths to the population than does youth 
or manhood, 

The causes of this great mortality of infants and children, and the means 
of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce it are to a considerable 



CAUSES OF INFANTILE MOETALITY. 25 

extent unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an early 
death. Cases of anencephalus, most cases of congenital hydrocephalus, of 
spina bifida, of cyanosis, are fatal before the close of infancy. These de- 
fects of formation we cannot detect before birth, and their causes are often 
obscure. Some of them seem to result from inflammation, believed to be, 
occasionally, syphilitic, developed at some period of foetal existence. Other 
internal malformations are attributable to perturbating influences, operating 
temporarily on the mother during gestation. But in a large proportion of 
cases, we cannot assign the cause. Obviously, only partial success can 
attend our efforts, as regards prevention in these cases, and almost no suc- 
cess, as regards the use of remedial measures. 

Another obvious cause of the great mortality of early life, is natural 
feebleness of system, especially in infancy. The younger the patient, prior 
to the middle period of life, the sooner are the vital powers exhausted by 
disease. Hence a larger proportion of infants succumb to the same 
malady than children, and a larger proportion of children than adults. 
This statement is true of infancy and childhood in general. It is a law in 
nature, and cannot be changed by art. But there are many infants born 
with hereditary disease, or a strong predisposition to disease, through a 
fault, which is, in a degree, curable, in the system of one or both parents, 
as, for example, the syphilitic, scrofulous, or tubercular diathesis. Parents 
seriously affected by such diseases cannot, without corrective treatment, 
have healthy offspring. Their children are among the first to droop and 
die, either directly from the inherited disease, or from feebleness of con- 
stitution, which such disease entails, and which renders them an easy prey 
to other diseases. The duty of the physician, as regards such parents, is 
obvious. He may, by therapeutic and hygienic measures, secure a more 
healthy progeny, and, so far as he can do this, he aids in diminishing the 
infantile mortality. He may sometimes, by timely measures directed to 
the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and impor- 
tance, especially as regards the city population. Inherited affections are 
less common in the country, but in the city they contribute largely to the 
number of deaths in early life. 

Another important cause of the great mortality of children, is the fact 
that they are peculiarly liable to certain severe and fatal maladies. I 
allude particularly to the acute infectious diseases, which, as a rule, occur 
but once, and that in childhood. Some of them, as scarlet fever, greatly 
increase the number of deaths. They extend and become epidemic through 
the intercourse of children. We are constantly witnessing in New York 
the spread of the acute contagious diseases, especially of whooping-cough, 
measles, scarlet fever, and diphtheria, through the schools. Measures 
employed, thus far, by boards of health, or other local authorities, to pre- 



26 MORTALITY OF EARLY LIFE. 

vent the dissemination of these and kindred diseases, have been but 
partially successful except in regard to smallpox. In the large public 
schools especially these maladies are most frequently contracted, and from 
them they radiate over the school districts. For if, as is now common, 
at least in New York City, a child comes to school wearing clothes which 
at home are hanging in a room where a brother or sister lies sick with 
measles or scarlet fever ; or if he enters the class with a mild pertussis or 
diphtheria, certain of his class-mates will probably return home infected 
with the virus of the disease. The same remarks are applicable, though 
with less force, to private schools. From both such schools I have over 
and over again witnessed the dissemination not only of the maladies men- 
tioned, but also of the milder infectious diseases, as mumps and varicella. 
The Health Board of New York city have recently, by stringent enact- 
ments regulating the schools, accomplished much in suppressing this source 
of the infectious diseases. 

In hospitals and asylums for children much can be done to prevent the 
occurrence of the infectious diseases by strict surveillance and prompt 
isolation of all suspicious cases. Without such care, scarcely a year passes 
in which these institutions are not scourged by one or more of these dis- 
eases. Much has been said of the crowding of families in tenement-houses 
so common in New Y r ork and other large cities, by which a large number 
of children are brought under one roof; of the uncleanliness of person 
and apartment to which it leads, and of the insufficient air and space 
which it allows to each. But one of the strongest objections, in my opinion, 
to the present plan of building and crowding tenement-houses is the facil- 
ity which it affords to the spread of the contagious diseases of childhood ; 
and it is in such houses, as shown by statistics, that these maladies are the 
most frequent and fatal. The much -needed enactments or regulations in 
relation to the construction and occupancy of such houses, would, among 
other salutary effects, greatly diminish the death-rate from the infectious 
maladies. 

Over the most loathsome, and formerly the most fatal, malady of man- 
kind, namely, smallpox, we now have, or can have, complete control by 
statutory enactments, enforcing vaccination. It is only by carelessness 
or the lack of sufficiently stringent regulations relating to the matter that 
smallpox is not " stamped out." Again, some of the most fatal inflam- 
matory diseases of life occur chiefly in childhood, as croup and capillary 
bronchitis. These and kindred diseases can only be prevented by proper 
hygienic management on the part of families, and books, or other means 
calculated to educate families in reference to the management of children 
cannot fail to diminish the number of cases of such inflammations, and 
consequently of the deaths from them. 

Another obvious and important cause of the mortality of early life, is 



LOCALITIES AND CLEANLINESS. 27 

the anti-hygienic condition or state in which many children live in conse- 
quence of the poverty or gross negligence of parents. 

Eesidence in insalubrious localities, personal and domiciliary uncleanli- 
ness, exposure without proper protection to vicissitudes of weather, are 
fertile causes of sickness and death. Hence one reason of the great infan- 
tile mortality among the city poor, who live in damp and dark alleys, and 
in crowded and filthy tenement-houses, breathing night and day an atmos- 
phere loaded with noxious gases. All physicians are aware how the 
malignant diseases, such as Asiatic cholera, cholera infantum, diphtheria, 
and typhus fever, seek the quarters of the city poor, and what terrible 
havoc they make there. All are aware, also, what wonderful recoveries 
occur, when feeble and attenuated infants, gradually sinking with chronic 
diseases, induced in great measure by this malaria, are transferred from 
such localities to the pure air of the country. 

Careless management of young children as regards dress increases 
greatly the liability to local diseases, such as commonly occur from expo- 
sure to cold. These are inflammatory affections, seated chiefly upon the 
mucous surfaces, but sometimes in parenchymatous organs. Adults, aware 
of the effect of sudden change of temperature from warm to cold, or of 
exposure to currents of air, protect themselves by additional clothing. 
Such precautionary measures are often lacking in the management of 
young children, and hence one cause of their great liability to local affec- 
tions, both of the respiratory and digestive organs. 

Routh, in his excellent treatise on Infant Feeding, says : "Among the 
most pernicious influences to young children, however, we may include 
cold ; the change of temperature from 45° to 4° or 5° below zero, as be- 
fore stated, producing an increase of mortality in London alone of three 
to five hundred. As out of one hundred deaths, however, from all speci- 
fied causes, nearly twenty -four occur to children under one, and thirty-six 
to children under five ; the great increase of mortality to children by cold 
is thus at once made obvious. Indeed, it is a household word amongst us, 
which takes its origin from the Registrar-General's returns, that a very 
cold week always increases the mortality of the very young and the very 
aged." 

Lastly, a very important cause of mortality in early life is the use of 
improper food. In infants, artificial feeding in place of the aliment which 
nature has provided for them, and, in children, the use of innutritious or 
indigestible articles of diet, give rise to diarrhceal maladies, emaciation, 
and death in numerous instances. Sometimes, also, defective alimentation 
is the cause of scrofulous or tuberculous ailments, and sometimes it gives 
rise to a cachexia or feebleness of system, which, without engendering 
any positive disease, renders those thus affected less able to support disease 
induced by other causes. A committee, of which Prof. Austin Flint, Jr., 
was chairman, appointed in 1867 to revise the " dietary table of the Chil- 



28 MORTALITY OF EARLY LIFE. 

dren's Nurseries on Randall's Island," states, with much truth and force : 
"Children .... are not capable of resisting bad alimentation, either as 
regards quantity, quality, or variety. At that age the demands of the 
system for nourishment are in excess of the waste ; the extra quantity being 
required for growth and development. If the proper quantity and variety 
of food be not provided, full development cannot take place, and the 
children grow up, if they survive, into puny men and women, incapable 
of the ordinary amount of labor, and liable to diseases of various kinds." 

Improper feeding, like other causes of mortality, is much more injurious, 
much more frequently the cause of death, in the city than in country. Sta- 
tistics in Europe, as well as this side of the Atlantic, establish this fact. 
It is in infancy, and especially in the first year, that the use of unwhole- 
some food entails the most serious consequences. No artificially prepared 
food is a good substitute for the mother's milk, and hence artificial feeding 
of the infant, unless under the most favorable circumstances, results dis- 
astrously. In the country, where salubrious air and sunlight conspire to 
invigorate the system, and a robust constitution is inherited, and where 
cow's milk fresh and of the best quality is readily obtained, lactation is 
not so necessary for the wellbeing of the infant ; but in the city its im- 
portance cannot be too strongly urged. 

The foundlings of the cities afford the most striking and convincing 
proofs of the advantages of lactation. In some cities foundlings are wet- 
nursed, while in others they are dry-nursed, and the result is always 
greatly in favor of the former. Thus, on the continent, in Lyons and 
Parthenay, where foundlings are w r et-nursed almost from the time that 
they are received, the deaths are 33.7 and 35 per cent. On the other 
hand, in Paris, Rheims, and Aix, where the foundlings are wholly dry- 
nursed, their deaths are 50.3, 63.9, and 80 per cent. 

In this city the foundlings, amounting to several hundred a year, were 
formerly dry-nursed ; and, incredible as it may appear, their mortality, 
with this mode of alimentation, nearly reached 100 per cent. Now wet- 
nurses are employed, for a part of the foundlings, with a much more favor- 
able result. 

These facts, to which others might be added from the experience of 
European cities, show the importance of lactation as a means of reducing 
infantile mortality in the cities. What has been stated as regards the re- 
sult of artificial feeding of foundlings, is true, in great measure, in refer- 
ence to all city infants. The ill effect of artificial feeding is well known 
in this city, and it is the common practice in families to employ a hired 
wet-nurse, if, for any reason, the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean it, 
the digestive organs are less frequently deranged by errors of diet. More 
substantial food, and considerable variety in it, may now be not only 



HINDRANCES TO LACTATION. 29 

safely allowed, but are required by the wants of the system. Still, the 
feeding of children in health, and much more in sickness, is a subject of 
great importance. Therefore lactation, and the diet of infancy and child- 
hood, will occupy our attention in the following pages. 



CHAPTER IV. 

LACTATION. 

It is desirable that the infant, as soon as it requires nutriment, should 
receive breast-milk. If it is fed, for a few days, with the bottle or spoon, 
it may be difficult finally to induce it to take the breast ; therefore it is 
well to determine early whether the mother will be able to wet-nurse her 
infant, so that, if unable, suitable provision may be made. 

The matter of determining, beforehand, the capability of the mother for 
wet-nursing has been investigated by Dr. Donne, of Paris, and in his 
treatise on Mothers and Infants he describes the mode in which it may be 
ascertained. The desired information, in his opinion, may be acquired by 
examining the colostrum, which is secreted in small quantity, in the last 
months of gestation, and which can be squeezed from the breast in suffi- 
cient quantity for inspection. 

In some women, according to Dr. Donne, the colostrum is so scanty that 
only a drop, or half a drop, can be obtained from the nipple by careful 
pressure. This will be found by the microscope to contain but few milk- 
globules, ill -formed, and a few granular bodies, such as the colostrum or- 
dinarily contains. Such women almost invariably furnish poor milk, and 
in small quantity. In other women the colostrum is abundant, but thin, 
resembling gum-water ; it lacks the yellow streaks and viscous character 
of ordinary colostrum, and it flows readily from the nipple. The milk of 
such women is sometimes scanty, sometimes abundant, but it is watery 
and deficient in nutritive principles. In a third class of women, the colos- 
trum is pretty abundant, and it contains yellowish streaks, of more or less 
consistence, which are found to be rich in milk-globules, of good size. 
Women furnishing such colostrum in the last weeks of gestation will have 
sufficient milk, and of good quality. These latter women make the best 
wet-nurses. 

Hindrances to Lactation and Physical Conditions rendering it 

Improper. 

The primipara often experiences difficulty in wet-nursing in consequence 
of a depressed state of the nipple. It is not sufficiently prominent to be 



30 LACTATION. 

readily grasped by the mouth, and after ineffectual attempts the infant 
becomes fretful when applied to the breast, and perhaps for a time refuses 
it altogether. Multiparas occasionally experience the same inconvenience, 
but it is not common when there has once been successful lactation. By 
calmness and perseverance on the part of the mother, the infant can 
usually be made to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipples should, 
indeed, in those who have never suckled, receive early attention, even 
before the birth of the infant. Tightness of dress around the breast, as 
indeed upon every part of the body, should be avoided, and from time to 
time gentle traction should be made upon the nipple, if it is depressed. It 
may be drawn out by the fingers of the mother several times each day, or 
by a common breast-pump, or by suction with a tobacco pipe, the edge of 
the bowl having been smoothed. Occasionally, in these cases of deficient 
nipple, the mother, fatigued and discouraged by her frequent ineffectual 
attempts to induce the infant to nurse, becomes feverish and excited, so 
that the quantity of her milk is sensibly diminished. The physician should 
assure her, as he usually can with confidence, that in a few days, as the 
baby becomes a little stronger, there will be no difficulty in its nursing. 
Some women are unremitting in their endeavors to procure nursing. This 
should be forbidden, since the lack of sleep, and the nervousness which 
such constant attention produces, tend to defeat the object which they have 
in view, by diminishing the secretion of milk. The application of the 
infant to the breast once in an hour and a half to two hours is quite suffi- 
cient. In some cases, when practicable, the aid of another woman, whose 
infant is a little older, is invaluable. The exchange of infants for a few 
times may remedy the difficulty. 

Occasionally lactation is rendered difficult and painful by too long delay 
before applying the infant to the breast. When the mother has rested 
a few hours after her confinement, about six in ordinary cases, lactation 
may commence. There is, at first, but very little milk, often only a few 
drops, but the secretion is promoted by nursing, so that the requisite 
amount is sooner obtained than when the infant is kept from the breast 
till the second or third day. If, as some physicians advise, suckling is 
deferred till the breasts are full and tender, and if, as is often the case 
with primiparas, the nipples are also tender, many mothers lack the forti- 
tude required to allow their infants to obtain a sufficient amount of milk. 
Excoriated and fissured nipples constitute a serious impediment to lacta- 
tion. They are very sensitive on pressure, and are long in healing. 
They are fully described in works which relate to female diseases, and 
their treatment pointed out. Occasionally fissured nipples do harm to the 
infant by the blood which escapes and is swallowed with the milk. A 
case is related in which positive indigestion was caused in this way, the 



HINDKANCES TO LACTATION. 31 

infant vomiting, after each nursing, milk mixed with blood. The local 
hindrances to lactation described above can, in most instances, be relieved 
in the course of a few weeks. 

There is, occasionally, a constitutional state of the mother which necessi- 
tates either the employment of a hired wet-nurse or weaning. This is the 
case when there is a strong tendency to tuberculosis. If the complexion 
is pallid, and the system at all emaciated, and suckling is attended by more 
or less exhaustion, and if with fair trial of wine and tonics there is no im- 
provement, the physician is justified in forbidding farther attempts at wet- 
nursing. If there is, under such circumstances, an hereditary tendency 
to tuberculosis, it is his duty to interdict it positively. The opinion of 
the physician, in such a matter, should be formed after mature delibera- 
tion. There are many women who, suffering temporarily from depression, 
and discouraged, are ready at once to abandon their infants to the care of 
others, with the least encouragement on the part of the physician to do so, 
but who, by attention to their own health, and especially by taking more 
sleep, soon recover from their depression and become good wet-nurses. 
On the other hand, night-sweats, a cough, and progressive decline in 
health, show the need of immediate suspension of wet-nursing. 

Sometimes women, prior to pregnancy, present indubitable evidence of 
tuberculosis, but by the improved general health which attends pregnancy, 
the disease is temporarily arrested. Such women should never suckle 
their infants. If they do, they soon lose all that was gained, and the disease 
advances rapidly. These objections to wet-nursing in such a state of health 
apply to the mother. There are also objections as regards the infant. 
The milk of those in decidedly infirm health, is deficient in nutritive prin- 
ciples. Their infants, therefore, are ill-nourished, and, if they have inherited 
a predisposition to tuberculosis, there is great danger that this disease will 
be developed in them ; whereas with healthy wet-nursing, even a strong pre- 
disposition may remain latent. M. Donne relates the following instructive 
cases, which show the danger which sometimes attends suckling, and the 
imperative necessity which may arise of discontinuing it. "A very light- 
complexioned young mother, in very good health, and of a good constitu- 
tion, though somewhat delicate, was nursing for the third time, and as re- 
garded the child successfully. All at once this young woman experienced 
a feeling of exhaustion. Her skin became constantly hot ; there were 
cough, oppression, night-sweats ; her strength visibly declined, and in less 
than a fortnight she presented the ordinary symptoms of consumption. 
The nursing was immediately abandoned, and from the moment the secre- 
tion of milk had ceased, all the troubles disappeared." " A woman of forty 
years of age .... having lost, one after another, several children, all 
of whom she had put out to nurse, determined to nurse the last one her- 
self. .... This woman, being vigorous and well-built, was eager for the 
work, and, filled with devotion and spirit, she gave herself up to the 



32 LACTATION. 

nursing of her child with a sort of fury. At nine months, she still nursed 
him from fifteen to twenty times a day. Having become extremely emaci- 
ated, she fell all at once into a state of weakness, from which nothing could 
raise her, and two days after the poor woman died of exhaustion. 

A very similar case recently occurred in my practice. A young and 
healthy woman from the country, suckling her second infant, on coming 
to the city, lived in a dark and very imperfectly ventilated room, on the 
first floor, and in the rear of a crowded tenement-house. She soon lost 
her appetite, but continued suckling for three months, when she became 
so anasmic and feeble that she was compelled to seek medical advice. She 
died without local disease, notwithstanding the most nutritious diet and 
the free use of stimulants and tonics. 

Constitutional syphilis in the mother does not contraindicate lactation. 
It is probable that the infant also has it. The mother should take anti- 
syphilitic remedies, which will eradicate the disease in herself, and also, if 
it be present, in the infant. Febrile affections, also, do not in general 
contraindicate lactation. They may, however, for a time, diminish the 
quantity of milk, or impair its quality. If, however, the mother is in a 
critical state, or much reduced, whatever the disease, suckling should 
cease. Whether or not the infant should be taken from the breast, if the 
mother is suffering from one of the essential fevers, depends on the 
severity of the malady, and the degree of her exhaustion. Twice I have 
known newly born infants nurse their mothers through attacks of scarlet 
fever, without contracting it, but suffering immediately afterwards from 
severe and protracted eczema. In the country, where artificially fed in- 
fants as a rule do well, it might be best to wean if the mother is affected 
with such a disease, but in the city eczema is less dangerous than the 
diarrhoeal affections which early weaning is apt to entail. In most cases 
of typhus or typhoid, weaning or procuring a wet-nurse is necessary, on 
account of the depression of the vital powers which this disease produces. 
Inflammatory affections, unless of a dangerous character, do not ordina- 
rily interfere with lactation, except that the quantity of milk may be 
somewhat diminished. In severe inflammation, it may be so necessary to 
husband the strength, or to keep the patient perfectly quiet, that suckling 
her infant would be injudicious. It should then be transferred to a wet- 
nurse or weaned. Inflammation of the breast often presents an impedi- 
ment to lactation. It is a common and painful affection, suspending, or 
greatly diminishing the secretion of milk in the affected gland. Nursing 
should cease as soon as there are evident signs of inflammation, unless it 
is limited to a small part of the gland. General heat of the breast, with 
tenderness and induration extending over a considerable part of it, indicate 
the need of the immediate removal of the infant from it. Lactation 
must be restricted to the unaffected side. It is often the case that the 
volume of the inflamed gland is considerably increased from the afflux of 



HINDRANCES TO LACTATION. 33 

blood to it, and from the interstitial exudation, while it contains little or 
no milk, and attempts at lactation, under such circumstances, are injurious 
to the mother as well as to the infant. The cause of the swelling should 
be explained to the mother, who commonly attributes it to the accumula- 
tion of milk, and worries herself and the infant, by attempts to make it 
nurse. As the inflammation abates, by resolution, or more commonly by 
suppuration, and the normal secretion returns, the first milk, which is apt 
to be thick and stringy, should be rejected, after which the infant may 
nurse as usual. Occasionally, the abscess, which has formed in the 
breast, connects with a lactiferous tube, so that pus may, on suction, 
escape from the nipple. If this occur, of course lactation should be inter- 
dicted until pure milk is obtained. Pus in the milk can sometimes be 
detected by the naked eye. It presents a yellowish or greenish color, 
occurring in streaks, when not intimately mixed with the milk. When 
it is intimately mixed, and in small quantity, it cannot be detected by the 
naked eye, but the microscope reveals the pus-globules. M. Donne relates 
a case in which he discovered pus-globules by the microscope, although 
there were at first no other evidences of an abscess, and doubts were 
expressed in reference to the accuracy of his observation. Finally, an 
abscess pointed and discharged. 

Sometimes, when the inflammation abates, the secretion does not return, 
and, worse still, occasionally the inflammation has occurred so near the 
nipple that the lactiferous tubes are permanently closed by it, so that, 
though milk forms in the breast, there is no escape for it. Thenceforth 
lactation must be entirely from one breast. 

If erysipelas occur in the mother, the infant should be immediately 
taken from her breast and from her arms. If this disease should not be 
communicated to the infant through the milk, or through fissures in the 
nipple, of which there is danger, still the milk is apt to undergo such 
change in consequence of the erysipelas as to endanger the health of the 
child. Thus, one of the wet-nurses in the New York Infant Asylum 
sickened with severe facial erysipelas on the 24th of April, 1875, eight 
days after the death of her baby. She was wet-nursing a foundling, aged 
seven weeks, at the time of the commencement of the erysipelas, and as 
it was very important that her milk should be preserved for the coming 
hot months, it was deemed best to allow the nursing to continue, the 
infant being placed in a crib at a little distance as soon as it dropped the 
nipple. On the 27th diarrhoea commenced in the baby. April 28th its 
morning temperature was 101°, and that of the evening 103°, the diar- 
rhoea continuing. It was now removed entirely from the breast, and was 
given artificial food. On the 29th there was a decided general icteric hue 
of the infant's surface, which continued till its death on May 1st. The 
stools numbered about eight daily till April 30th, when they ceased. The 
record which I preserved does not state whether there was vomiting, but 
3 



34 LACTATION. 

it had probably been slight on account of the speedy prostration. Death 
occurred from exhaustion. At the autopsy, from half an ounce to one 
ounce of pus was found in the peritoneal cavity, newly formed fibrin was 
observed upon the spleen and liver, and the peritoneum generally had 
lost much of its lustre ; a careful microscopic examination of the liver 
and its ducts, made by Dr. Heitzmann, revealed no anatomical change 
which would explain the icteric hue, and it seemed probable that this was 
due to the altered state of the blood. The mucous membrane of the 
intestines exhibited vascular streaks, and its follicles were distinct. The 
lesions therefore indicated intestinal catarrh. Nothing unusual was ob- 
served in the heart and lungs of the infant. Its life had apparently been 
sacrificed by the unhealthy nursing. 

Facts and Rules in reference to Lactation. 

The new-born infant may nurse often, even every hour during the day- 
time, till it is two weeks old, after which it should take the breast quite 
regularly every second or third hour in the daytime, and every third or 
fourth hour at night. An infant in ordinary health and obtaining a suffi- 
cient quantity of good milk every second hour from its mother, does not 
require to nurse more than once or twice during the hours which the 
mother needs for sleep, and by a little perseverance its habits may be so 
established that it requires the breast no oftener. After the third or fourth 
month it is proper to allow a little artificial food in addition to the breast 
milk, as we will see hereafter. Many young mothers commence the duty 
of suckling with too much ardor. Exerting themselves to the utmost for 
the good of their offspring, they are awake, night after night, giving their 
breast at every cry, till they find that their strength is failing, and with it 
also their milk. Their self-devotion necessitates early w r eaning, whereas, 
had they exercised more regard for their own health, and learned to hear 
with composure the cries which often do not indicate any bodily want 
or distress, they might have continued to suckle the infants during the usual 
period. 

The milk secreted during gestation, and immediately after the birth of 
the infant, differs in its gross appearance, as well as chemical and micro- 
scopical characters, from that which is ordinarily secreted during lacta- 
tion. It is termed Colostrum. It has a turbid and yellowish appear- 
ance, and is somewhat viscid. It is decidedly alkaline, and undergoes 
lactic acid fermentation more readily than common milk, and it also con- 
tains more solid matter. It has an excess of fat, of salts, and, according 
to Simon, also of sugar. It appears, from Simon's analysis, that the solid 
matter of colostrum is about seventeen per cent., while that of the ordi- 
nary breast-milk is about eleven per cent. 

Examined by the microscope, the colostrum is seen to contain oil-glob- 



FACTS AND RULES IN REFERENCE TO LACTATION. 35 

ules and a viscid substance, which often assumes an ovoid or globular 
form, but which also exists in irregular masses of considerable size. This 
substance has been thought by some to be mucus, but it is dissolved by 
acetic acid and potash, and is tinged yellow by a watery solution of iodine. 
It is, therefore, to be regarded as albuminous. Imbedded in this sub- 
stance are oil-globules, which are for the most part of small size, while 
the free oil-globules of colostrum are larger than those occurring in 



Fig. 2. 



Q' 3 



S°_© 



„°9 



©® 



Oj>'b Q 









'©O 



dgo 



Milk-globules. 




Colostrum-corpuscles. 



healthy milk. This viscid substance, with the imprisoned oil-globules, 
constitutes what has been designated the " colostrum-corpuscles." Some 
have erroneously considered the " colostrum-corpuscles" to be compound 
granular cells. The compound granular cell, or corpuscle, is a cell which 
has undergone fatty degeneration. It is distended with oil-globules to 
perhaps twice or thrice its normal size. On the other hand, examination 
of the "colostrum-corpuscles" fails to detect a cell-wall, and the large 
and irregular size of some of these corpuscles negatives the idea that they 
are cells. The oil-globules contained in the viscid substance are more 
readily acted on by ether than are the free oil-globules. 

The colostrum is replaced by milk of the normal character, in six to 
eight days : sometimes as early as the third or fourth day after delivery. 
In exceptional instances, the colostrum does not disappear for several 
weeks, and it may reappear at any time during lactation, as a consequence 
of derangement of the system, or from disease. It is assimilated with 
difficulty by the digestive organs of the infant, producing usually a laxa- 
tive effect. It, therefore, aids in the removal of the meconium, and being 
a normal secretion in the first week of lactation, it is to be regarded as 
beneficial. Continuing longer than the first week, its effect is deleterious. 
It produces evident derangement of the digestive organs, and the infant 
that habitually nurses it never thrives. It has diarrhoea or vomiting, be- 
comes more or less emaciated, and suffers from colicky pains. Sometimes 
an extreme degree of exhaustion is reached before the cause is suspected, 
for if the milk is pretty abundant, the admixture of colostrum with it can- 
not be detected by the naked eye. The microscope alone reveals it. The 
following is an interesting example of this fact. In 1868 an infant six 



36 LACTATION. 

weeks old was brought to me, with the following history. The mother had 
for years been troubled more or less with dyspeptic symptoms, but had 
otherwise been in good health. The infant at birth was fleshy and strong, 
but after the first week it had never thriven like other infants. It nursed 
regularly, and the quantity of milk was apparently sufficient, but it 
vomited as soon as it ceased nursing ; it was much emaciated, and the 
bowels were habitually constipated. The digestive organs of the infant 
had been in this unhealthy state, with little variation, from the first week, 
and it was very evident, from the emaciation and exhaustion, that it must 
soon perish, unless some change were effected. The milk of the mother 
presented the usual appearance to the naked eye, but under the micro- 
scope colostrum-corpuscles were observed. A wet-nurse was immediately 
obtained, and from that moment the gastro-intestinal symptoms disap- 
peared with a rapid recovery. This case shows at once the evil effects of 
the colostrum, and the need of a microscopic examination of the milk 
whenever the nursling suffers from lactation. 

Human Milk. 

The specific gravity of human milk is about 1032. It has been care- 
fully analyzed by different chemists, with nearly the same result. The 
following table, prepared by MM. Vernois and Becquerel, gives the pro- 
portion of the various ingredients in 1000 parts : — 

Water 889.08 

Sugar 43.64 

Casein and extractive 39.24 

Butter 26.66 

Salts (ash) 1.38 

1000.00 

Milk, being the sole food of early infancy, contains all the nutritive 
principles which are required for the growth and repair of the different 
tissues. The casein is an albuminous principle, the butter and sugar are 
combustible substances, and most of the salts which occur in the different 
tissues exist primarily in the milk. Phosphate of lime, phosphate of 
magnesia, phosphate of the peroxide of iron, chloride of potassium, chlo- 
ride of sodium, and soda, known to exist in cow's milk, are believed to 
occur also in human milk. Epithelial cells are sometimes present, derived 
from the lining membrane of the lactiferous tubes. 

Modification of the Milk in consequence of the Diet. 

Fresh milk should give an alkaline reaction, but in certain states of ill 
health, or after the use of certain articles of food, the reaction is acid. 
Mothers are well aware of the ill effects, as regards the infant, which 



MODIFICATION OF THE MILK BY THE DIET. 37 

follow their use of indigestible, or acescent food ; and, if prudent, they 
avoid it. The milk, if the diet of the mother is improper, may become 
so strongly acid as to cause colicky pains and diarrhoea. The following 
observations in reference to cow's milk are instructive. We may infer 
from them that the regimen of the mother exerts a decided influence on 
the alkalinity of her milk. According to Routh {Infant Feeding, page 
285), stall-fed cows almost always give acid milk. Dr. Mayer, of Berlin, 
examined the milk from a considerable number of cows, with the follow- 
ing result : — 

(«.) Of cows fed with brewers' lees, red potatoes, rye bran, and wild 
hay, in five instances the milk was slightly acid ; in one very much so. 

(b.) Of forty cows fed with potato mash, barley husk, and clover and 
barley straw, in ten, which were examined, the milk was acid ; in three 
very acid. 

(c.) From among fifty cows fed on potato husks, barley husks, and wild 
hay, five were examined, and in all the fresh milk was acid. 

(rf.) From forty-two cows fed on potato mash, husks, wild hay, and 
rye straw, out of twelve selected for examination, the fresh milk of all 
was acid. 

(e.) From six cows fed by a chief gardener on coarse beet-root, red 
potatoes, bran mash, and hay, the fresh milk was slightly acid. 

(f.) From five cows fed by a cow-feeder on lukewarm bran mash and 
hay, in four the fresh milk was quite neutral, in one it was decidedly 
alkaline. {Routh.) 

The above observations of Dr. Mayer were made in the winter season, 
and it is possible that the acidity may have been partly due to the confine- 
ment of the cows in stalls. But that it was mainly due to the food is 
evident from the fact that it was greater with some kinds of food than 
others. Cows' milk is not so alkaline as human milk, and is therefore 
more readily rendered acid. Still, what Dr. Mayer observed in reference 
to the cow exemplified a fact of general applicability, namely, that certain 
kinds of food may affect the alkalinity of the milk, whether human milk 
or that of animals. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet is poor, the amount of water increases, 
and that of butter and casein diminishes. Lehmann says (Phys. Chem- 
istry, vol. ii. p. 65) : " From experiments made on bitches, it would 
appear that a vegetable diet renders the milk richer in butter and sugar ; 
while the solid constituents are augmented when a sufficient quantity of 
mixed food is given. Peligot found the milk of an ass most rich in casein 
when the animal had been fed on beet-root ; whilst it was richest in butter 
when the food had consisted of oats and lucerne. Fat food increases the 
quantity of the butter. Boussingault found the milk of a cow richer in 
casein when the animal had been fed on potatoes than when other food 



38 LACTATION. 

was taken. Reiset found that the milk of cows which were at grass was 
much richer in fat than when the animals had stood all night in their stall 
without food ; but Playfair found, on the contrary, that the quantity of 
butter in the milk increased during the night as much as during their stall- 
feeding, but that the quantity of butter in the milk was considerably 
diminished by the motion of the animals in the fields." 1 Simon made the 
following analyses of the milk of a poor woman. She was suddenly, 
during the period of lactation, deprived of the means of support, so that 
her food was insufficient in quantity, and of poor quality. The amount 
of her milk was not diminished by privation, but the solid constituents 
were reduced to 86 parts in 1000. After this, for a time, her diet was 
nutritious and abundant, the quantity of milk was increased, and the solid 
constituents amounted to 119 parts in 1000. Her diet was again reduced, 
with a reduction of the solid elements to 98 in 1000, and, at a later period, 
the diet was again nutritious, with an increase of the solid elements to 
126. The chief variation observed in the milk of this woman was in the 
amount of butter. 

Modification of Milk from its retention in the Breast. 

M. Peligot has clearly demonstrated, that the longer milk is retained in 
the breast the more watery it becomes. This is explained on the supposi- 
tion that the solid portion is first absorbed. Therefore, the milk is richer 
the more frequently it is removed from the breast. A similar fact, which 
has the same explanation, has long been known, namely, that the first 
milk taken from the breast is thinnest, while that which flows last is 
richest. That first removed has remained longest in the gland, while that 
which comes last is but recently secreted. 

A knowledge of this fact is of considerable practical importance. The 
milk, as M. Donne has shown, may be too rich, so as to cause indigestion, 
with more or less enteralgia, in the infant. Some nurslings, if the milk is 
too rich and abundant, reject a part of it by vomiting, but others do not, 
and suffer the consequence in derangement of the digestive organs. For 
such cases the remedy is, to give the breast less frequently, by which a less 
amount of milk is taken, and milk of a poorer quality. On the other 
hand, if there is poverty of the milk, and the infant is insufficiently nour- 
ished, the milk is more nutritious, if the nursing be at short intervals. 

Modification of Milk by Age and by Mental Impressions. 

The composition of the milk varies, also, according to the age of the 
infant. Simon analyzed the milk of a woman at intervals for the period 

1 Animal Chem., Sydenham's Soc.'s Trans., vol. ii. p. 55. 



MODIFICATION OF MILK BY CATAMENIA, ETC. 39 

of about six months. In this case the amount of casein at first was small, 
but the quantity increased during the two months succeeding delivery, 
after which it was nearly stationary. A similar increase was observed in 
reference to the saline substances. The sugar, on the other hand, dimin- 
ished in quantity as the infant grew older, its maximum amount being in 
the first and second months. The quantity of butter in the milk varies 
from day to day more than the other elements. 

Many observations have been published which show that the composi- 
tion of the milk may be materially changed by mental impressions. The 
infant has died suddenly in the act of nursing, after his mother had been 
violently excited. Such a case is related by Tourtnal. The infant ceased 
nursing, gasped, and died in the mother's lap. In other cases convulsions 
have occurred. MM. Becquerel and Vernois made the chemical analysis 
of the milk of a woman in a state of nervous excitement, and found that 
the solid constituents were diminished to 91 parts in 1000, the most marked 
diminution being in the butter, which was only about 5 parts. In a case 
related by Parmentier and Deyeux the milk became watery and viscid, 
and remained so till the nervous attacks, from which the patient suffered, 
had ceased. Dairymen are well aware how ill-treatment and the separa- 
tion of the calf from the cow diminishes the milk which she yields. A 
new milkman seldom obtains as much milk as one with whom the cow is 
familiar. Bouchut, alluding to the influence of the moral affections on the 
secretion of milk, makes the following remark, the truth of which most 
mothers will acknowledge: " It is also a fact, that the sight of the nurs- 
ling, the idea of seeing it at the breast, and the joy which certain mothers 
thence experience, exercise a moral influence over the secretion of the milk 
entirely independent of their will. They feel the draught of milk as soon 
as they behold their child, or think of it too deeply ; and in a woman who 
saw her child fall to the ground, the flow of milk ceased, and did not 
reappear until the child, having quite recovered, attempted to take the 
breast." 



Modification of Milk by the Catamenial Function and Pregnancy. 

The catamenia reappear in most women before the close of lactation, 
often by the fifth or sixth month after delivery. If this function is re-es- 
tablished in the normal manner, that is, without any derangement of the 
system, without pain or undue profuseness, no unfavorable result ordi- 
narily occurs with the infant. On the other hand, if the mother suffer any 
disturbance of the system, or if the menses are profuse, the lacteal secre- 
tion may be so changed that the infant is injuriously affected by it. The 
symptoms produced are those of indigestion, such as abdominal pains, more 
or less vomiting, and diarrhoea. This result is, however, in my experi- 
ence, quite exceptional. In rare instances, more dangerous symptoms 



40 LACTATION. 

occur in the infant. A case has been reported to me in which, at each 
catamenial period, the nursling was seized with convulsions. 

MM. Becquerel and Vernois have investigated the character of the milk 
during the catamenia in three cases. Their examinations showed a mode- 
rate increase in the solid constituents. The butter and casein were in- 
creased, while the sugar was diminished. The variation from normal milk 
was not, however, such as would be likely to cause any serious indisposi- 
tion. If the menses reappear with regularity, when the infant has attained 
the age of ten or twelve months, they should be considered as designed to 
supersede the secretion of milk, which, indeed, usually begins to diminish. 
"Weaning is then proper. If the menses return early in the period of lac- 
tation, and give rise to symptoms in the infant in consequence of the 
altered quality of the milk, it is advisable to allow but little nursing dur- 
ing the catamenia, and to employ artificial feeding instead, till the flow of 
blood ceases. 

The change produced in the milk by pregnancy is, in general, more in- 
jurious to the nursling than that caused by the reappearance of the menses. 
The milk of the pregnant woman is apt to contain more or less of that 
viscid substance which characterizes colostrum. Still, the milk of preg- 
nancy does not, ordinarily, derange the digestive function as much as 
colostrum, in the first weeks of lactation, for pregnancy rarely occurs till 
after the infant is five or six months old, when the organs of digestion are 
less readily disturbed. The injurious effect of pregnancy on the infant is 
shown by vomiting or diarrhoea, by restlessness and occasional abdominal 
pains, in fine, by symptoms of indigestion. In many cases, however, these 
symptoms do not occur, and the infant, though nursing regularly, con- 
tinues to thrive. ~No doubt, as a rule, the infant should be weaned when 
there are clear evidences of pregnancy, but under certain circumstances 
weaning is injudicious. I have, on different occasions, been called to in- 
fants, in midsummer, dangerously sick with diarrhoeal attacks induced by 
this cause. These infants were, perhaps, doing well, or suffering but little 
from indigestion, when the mothers, suspecting themselves pregnant, at 
once withdrew them from the breast, and cholera infantum or a kindred 
disease was the result. No infant in the city should be weaned in the hot 
months. It is much safer, though there are indubitable signs of preg- 
nancy, that it continue nursing till the cold weather. The better method 
is, however, under such circumstances, to employ a wet-nurse, or to re- 
move the infant to the country, and wean it there. In cold weather, it is 
usually safe to wean an infant in the city after it has reached the age of 
five or six months. 

The milk frequently contains other ingredients in addition to those 
which have been mentioned. Thus a large number of medicinal sub- 
stances, taken by the mother, may enter the milk, so as to produce their 
characteristic effect on the infant. It is a well-known fact, that the pecu- 



QUANTITY OF BREAST MILK REQUIRED BY INFANT. 41 

liar flavor of certain vegetables, taken as food, may be noticed in the milk. 
It is admitted, also, that the specific virus of the contagions diseases, at 
least certain of them, may enter the milk, so as to give rise to the same 
diseases in the infant. 



Quantity of Breast Milk required by the Infant. 

In a paper published by Dr. W. H. Cumming, in the American Journal 
of the Medical Sciences, July, 1858, it is estimated that the amount of milk 
secreted per day by a healthy woman is one and a half to two quarts, and 
double the quantity if two infants are suckled. Eouth {Infant Feeding, 
page 87) believes that this is a somewhat exaggerated statement. He 
estimates the amount at a quart to a quart and a half daily. " A three 
months' child," says he, " generally thrives very well on four or, at the 
most, five meals a day, the quantity taken each time amounting to a half 
pint. This would fix the quantity at two pounds to two and a half, i. e., 
thirty-two to forty fluidounces. ... A younger child, one to two months, 
may need to take his meals more frequently ; it may be every two hours, 
except when asleep ; but then the quantity consumed does not exceed, as 
a rule, as I have often assured myself, two wineglasses or three ounces 
every meal. This would raise the quantity taken in twenty -four hours to 
thirty-six ounces, a quart and a quarter. A child above three months 
may take about forty-eight ounces daily." 

Dr. Cumming, in consequence of his high estimate of the amount of 
milk which an infant requires, naturally concludes that few mothers can 
long endure the excessive drain upon their systems ; and, therefore, in 
order to prevent their exhaustion and to satisfy the appetite of their in- 
fants, it is necessary, at an early period, to aid by artificial feeding. This 
opinion may do harm, since artificial feeding of the young infant, espe- 
cially in the cities, is apt to give rise to indigestion, followed by vomiting 
and diarrhoea. The mother in good health, and furnishing an average 
quantity of milk, is competent to give all the nutriment which the infant 
requires until it has reached the age of four months, and most are till the 
age of six months. Drs. Merei and Whitehead examined 952 mothers in 
the Children's Hospital at Manchester, in reference to their physical con- 
dition. Of these 629, or QQ per cent., were in a healthy and robust state. 
Of this number, namely 629, 420 furnished sufficient milk till six months 
after delivery, and some till two years. 

Differences in Suckling Women as regards Quantity and Quality of 

Milk. 

There is, however, a great difference, in different women, as regards the 
quantity and quality of their milk, and even the mode in which it is 



42 LACTATION. 

secreted. The best wet-nurses are usually robust without being corpulent. 
Their appetite is good, and their breasts are distended from the number 
and large size of the bloodvessels and milk-ducts. There is but a mode- 
rate amount of fat around the gland, and tortuous veins are observed 
passing over it. Such nurses do not experience a feeling of exhaustion 
and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own 
sustenance and the supply of milk. There are other good wet-nurses who 
have the physical condition which I have described, but whose breasts are 
small. Still, the infant continues to nurse till it is satisfied, and it thrives. 
The milk is of good quality, and it appears to be secreted, mainly, during 
the time of suckling. Other mothers evidently decline in health during 
the time of lactation. They furnish milk of good quality and in abun- 
dance, and their infants thrive, but it is at their own expense. They 
themselves say, and with truth, that what they eat goes to milk. They 
become thinner and paler, are perhaps troubled with palpitation, and are 
easily exhausted. They often find it necessary to wean before the end of 
the usual period of lactation. There is another class whose health is 
habitually poor, but who furnish the usual quantity of milk without the 
exhaustion experienced by the class which I have just described. The 
milk of these women is of poor quality. It is abundant, but watery. 
Their infants are pallid, having soft and flabby fibre. All these kinds of 
wet-nurses are met in practice. 

Occasionally, a considerable part of the milk is lost by oozing from the 
breast. This sometimes occurs in robust women, but it is more frequently 
associated with weakness. It is then due to a relaxed state of the orifices 
of the milk-ducts. Galactorrhea, as the excessive secretion and flow of 
milk is designated, is said to be often associated with a menorrhagic dia- 
thesis ; that is, women whose menses have been profuse are apt to have 
too abundant a flow of milk corresponding with the menorrhagia. It is 
said that galactorrhea is also apt to occur in those who are subject to 
discharges from parts which sustain no immediate relation to the breast, 
as in cases of hemorrhoidal flux, diabetes insipidus, etc. Excitement, or 
irritation of the uterus or ovaries, may serve as an exciting cause of 
galactorrhea in those predisposed to it, and excessive suckling may have 
the same effect. 

Scantiness of Milk ; its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is less 
than was estimated by Cumming, still insufficiency of this secretion is not 
uncommon, especially in the cities. According to the statistics of Drs. 
Merei and Whitehead, among healthy mothers there is insufficiency in 
16.5 per cent., while among mothers in feeble health the percentage is 



SCANTINESS OF MILK. 43 

46.6. In treating of this subject in the following pages, reference is not 
had to those cases in which there is temporary diminution of milk from 
acute disease or other perturbating causes, but to those cases in which 
there is habitual scantiness. 

One cause of scanty secretion of milk is a life of privation or of daily 
work, which necessitates separation from the infant. Insufficient food may 
render the milk more watery, as has already been stated, or it may cause 
diminution in its quantity. The mother thus situated is pallid. She is 
subject to palpitation and attacks of faintness. Her condition, indeed, is 
that of anaamia. Working women have scantiness of milk, not only in 
consequence of hardships, but also because they are usually separated for 
hours from their infants. Age is also a cause of scantiness of milk. 
Mothers at the age of forty years ordinarily furnish less milk than be- 
tween twenty and thirty. And those who have not borne children till 
late in life, and whose mammary glands have therefore long been inactive, 
have less milk than those who commence bearing children at the usual 
period. v 

Eouth speaks of hyperemia as a cause of defective lactation. " This 
is a variety," says he, " which I have chiefly observed among hired wet- 
nurses, selected from the poorer classes, and admitted into wealthier 

families When feeding at the expense of a master or mistress, the 

amount they devour often surpasses all moderate imagination. They, in 
fact, gormandize. If in such instances a wet-nurse is given all she asks 
for, she will be found often to eat quite as much as any two men with 
large appetites ; and, as a result, she becomes gross, turgid, often covered 
with blotches or pimples, and generally too plethoric to fulfil the duties of 
her position. The plethora, as first induced, is of the sthenic variety, but 
it soon assumes an asthenic character, and, as the immediate result, the 
breast no longer secretes its quantum of milk. There may be good milk 
secreted, but it is in small quantity, and this quantity diminishes daily. 
The breast may also enlarge, but it is from a deposition of fatty tissue in 
and about it, as in other parts of the body. The veins on the surface be- 
come less apparent, always a bad feature in a suckling breast, till finally 
the flow of milk ceases altogether." 

Atrophy of the breast from the employment of iodine, or from long dis- 
use, is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant that the 
milk should be in proper quantity as well as quality, that it is proper in a 
work of this kind to consider the treatment of insufficient secretion, and, 
on the other hand, of excessive secretion and loss of milk, or galactorrhea. 
And first of insufficient or scanty secretion. 

The most efficient mode of increasing the lacteal secretion is that which 
is also natural, namely, suction from the nipple. There are many cases on 
record in which this has produced the flow of milk in women who have 



44 LACTATION. 

never borne children, and even in men. Baudelocque mentions the case 
of a girl, eight years old, who suckled her brother for a month, and cases 
at the opposite extreme of life have been reported ; one of a woman of 
seventy years, who wet-nursed a grandchild twenty years after her last 
confinement. 

The following case, which was under my observation, is interesting in 
this connection : Lizzie S. was confined with her first child on May 30, 
1876. When the baby was a few days old, and before she had left the 
bed, she had inflammatory symptoms which proved to be due to pelvic 
cellulitis. Its course was tedious ; her milk diminished, and its secretion 
soon ceased. On or about the first of August she began to sit up, and on 
August 11th she was admitted into the Sixty-first Street branch of the 
Infant Asylum, pale and wasted, but with returning appetite. She had 
had no mammary secretion for eleven weeks, and her breasts were small 
and flabby. She had two fistulous openings, one vaginal, and the other 
low clown in the back, near the lower end of the sacrum or the coccyx. 
The baby was in a fair condition, having been suckled by other women. 
Experiences in this and other institutions show that infants having breast 
milk do far better and are much more apt to live than those without breast 
mill:, and the mother was therefore advised by one of the managers — him- 
self a physician — to suckle her baby, although there was not a drop of milk 
in her breast, and nursing had been suspended eleven weeks. To the 
surprise of the mother, and of the nurses in the house — to whom the pro- 
cedure seemed very ridiculous — milk began to appear in a few days. The 
mother left the institution October 8th ; but before her departure she was 
able to furnish, perhaps, two-thirds the quantity of milk which her infant 
required. This case affords practical illustration of the fact that frequent 
nursing is the most efficient galactagogue. Mothers sometimes, having 
little breast milk, suckle their babies at long intervals, and finally, dis- 
couraged at the unproductive state of their breasts, resort to weaning, 
when, by patience and more frequent lactation, they might become good 
wet-nurses. In the cities, and during the summer season, in which breast 
milk is so much required, the history of cases like the above, and the more 
remarkable cases in which men and grandparents have had secretion of 
milk and have suckled infants, should induce the physician to withhold 
his consent to premature weaning, which the disheartened mother is apt 
to suggest, unless indeed he perceive other reasons for weaning apart from 
scantiness of milk. 

Travellers among barbarous nations or tribes have often observed these 
cases of unnatural lactation. Humboldt saw a man, thirty-two years old, 
who gave the breast to his child for five months, and Captain Franklin, 
in the Arctic regions, met a similar case. Dr. Livingstone, in his African 
travels, says that he has examined several cases in which a grandchild has 
been suckled by a grandmother, and equally remarkable instances of lac- 



SCANTINESS OF MILK. 45 

tation occur among the negroes of the Southern and Middle States. Pro- 
fessor Hall presented to his class in Baltimore a male negro fifty-five years 
old who wet-nursed all the children of his mistress. In these cases of 
abnormal lactation, so far as we have accurate records of them, it is ascer- 
tained that the breasts were torpid, and even sometimes, as in old people, 
atrophied till the nursing commenced. Titillation, or pressing of the nip- 
ple, caused an afflux of blood to the gland, and developed its functional 
activity, so that milk was produced for the sustenance of the nursling. 
Therefore, in case of scanty secretion of milk, the mother may increase 
the quantity by applying the infant often to the breast. If, dissatisfied 
with the small amount of nutriment which it receives, it refuses to make 
the necessary suction, any other mode of gentle traction or pressure may 
be employed in addition. The occasional employment of another infant, 
or a pup, milking the breast with the thumb and fingers, or the gentle 
suction of a breast-pump, aids in stimulating the secretion. One of the 
best breast-pumps kept in the shops is that to which the name The Moth- 
er's Blessing has been applied. Forcible rubbing or traction of the breast 
defeats the purpose for which it is employed. It produces too much irri- 
tation and tenderness. The best mode of stimulation is by nursing, as it 
is the natural mode, and the moral effect of the infant at the breast aids 
in promoting the secretion. 

Another mode of increasing the functional activity of the mammary 
glands is by the electrical current. The fact is established by physiologi- 
cal experiments, that glandular organs can be made to secrete more ac- 
tively by the stimulus of electricity, and, accordingly, this agent has been 
successfully employed to promote the secretion of milk. In Routh's In- 
fant Feeding several cases are related which show the beneficial effects of 
this agent (page 149 et seq.). Among them are six reported by Dr. Skin- 
ner, of Liverpool. In all these, one or two applications of the electrical 
current sufficed to restore the secretion. The following is Dr. Skinner's 
mode of employing this treatment : — 

" 1. Direct — Both poles must terminate in cylinders, with sponges well 
moistened in tepid water. The positive pole is pressed deep into the axilla, 
while the negative is lightly applied to the nipple and the areola; the cur- 
rent being no stronger than is agreeable to the patient's feelings. The 
poles are kept in this position for about two minutes. 

" 2. Intramammary — The poles are to be, as it were, imbedded in the 
mamma, and moved about, raising and depressing both poles at once in 
and around the organ for the space of another two minutes. The same is 
to be done to both breasts daily, until the secretion is properly established. 
Hitherto one or two sittings have always sufficed in my hands." ( Com- 
munication of Dr. Skinner to Dr. Routh.) 

In all cases of scanty secretion of milk, the regimen of the mother is a 
matter of importance. Personal and domiciliary cleanliness is essential 



46 LACTATION. 

for successful wet-nursing. A certain amount of exercise in the open air 
is conducive to the health of the mother, and to the secretion of abundant 
and healthy milk. A case is related to show the effect of fresh air and 
outdoor exercise on the lacteal secretion. A lady of cleanly habits, liv- 
ing in London, had a very scanty supply of milk. She removed to the 
pure air of the seashore, and immediately the quantity became abundant, 
and continued so for months. Such cases are not unfrequent. A mode 
of life that contributes to the general health of the mother will not fail to 
augment the quantity of her milk, if it is scanty, and to improve its 
quality. 

Much has been written in reference to the diet of women who suckle. 
It is a popular belief that certain articles of food promote the secretion of 
milk much more than other articles, though equally nutritious. No doubt, 
writers have erred in recommending exclusively this or that kind of food, 
as most likely to produce milk. The exact kind of food which is prefer- 
able, in a certain case, depends partly on the physique of the individual, 
and partly on the character of the food to which she has been accustomed. 
A mixed diet contributes most to the sustenance of the mother, and to 
an abundant secretion of milk. Animal substances which furnish a due 
supply of nitrogenous aliment should be given with the farinaceous. 
Mothers pallid, and inclining to an anaemic condition, require a larger 
proportion of animal diet than those in good general health. On the 
other hand, plethoric women, such as Eouth describes, who with excellent 
appetite consume large quantities of food, and who become more and 
more full-blooded and corpulent while the milk diminishes, require a more 
restricted animal diet, in connection with more exercise, especially in the 
open air. 

There are certain kinds of food which do appear to have a galactogogue 
effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses 
often remark, after taking a bowl of this, that they feel the flow of milk. 
Cow's milk with some has a similar effect. Porter or ale, taken once or 
twice a day, also promotes the secretion of milk, especially in those who 
have noor appetite, and whose systems are somewhat reduced. 

A great variety of medicines have been used for their supposed galac- 
too-os;ue effect. Medicines which improve the general health are, no 
doubt, sometimes useful for this purpose, such as the vegetable and ferru- 
ginous tonics and, perhaps, cod-liver oil. But there are other medicines 
which it is claimed have a specific effect on the mammary gland, pro- 
moting its secretion. Lettuce, winter-green, fennel, the broom tops (sco- 
parius), and marsh-mallow, have been used for this purpose. There can 
be no doubt that the aromatic stimulants, as fennel, anise, and caraway 
seeds, given in soups, sometimes stimulate the lacteal secretion. Another 
medicine which of late has been recommended to the profession, as a galac- 
too-oo-ue, is castor oil and the plant from which it is derived. 



SCANTINESS OF MILK. 47 

The galactogogue effect of the leaves of the castor oil plant has been 
long known to the Spaniards in South America. At least as long ago as 
the commencement of the last century the ricinus communis was applied 
by them externally to the breast to promote the secretion of milk. It is 
now about twenty years since this use of the plant was brought promi- 
nently to the notice of the profession in this country and in Europe. In 
the London Journal of Medicine, 1857, Dr. Tyler Smith relates the re- 
sults of his experiments with the castor oil plant. He applied the bruised 
leaves over the breasts, and witnessed, as he thinks, an evident galacto- 
gogue effect. Dr. Eouth has also made pretty extensive use of the plant, 
both externally and internally. He was led, he says, to employ it inter- 
nally, from noticing in suckling women an increase of milk after taking 
a dose of castor oil. He prescribed a decoction of the leaves and stalks, 
and says : " I have not been disappointed. The flow has been remarkably 
increased. Four objections against its use, however, should be mentioned." 
These are, first, a peculiar sensation in the eyes, with dimness of sight, an 
effect wdiich he has observed only in weak women ; secondly, the necessity 
of increasing the dose as the patient becomes accustomed to it ; thirdly, 
scarcity of the plant ; fourthly, an occasional diuretic, sometimes without 
galactogogue effect, and sometimes with it. The cases in which diuresis 
occurred were in the practice of other physicians, and Dr. Routh conjec- 
tures that this effect was produced by not keeping the breast warm during 
the time that the decoction was being employed. The breasts should, at 
the time of its use, be covered w T ith a fomentation of leaves, or an extract 
of the leaves should be rubbed over the breasts in the same w r ay in which 
extract of belladonna is used, and over this a warm poultice applied of 
the ordinary material. Dr. Routh remarks : "When the castor oil leaves 
are given as an infusion to women who are not suckling, I have observed 
two effects, both of which seem to denote its specific action. First, it 
produces internal pain in the breasts, which lasts for three or four days. 
Then, secondly, a copious leucorrhceal discharge takes place, after w^hich 
the effect on the breasts entirely disappears." 

Dr. Gilfillan, of Brooklyn, has also employed the ricinus communis 
successfully as a galactogogue. He employed a poultice of the pulverized 
leaves, and gave internally the fluid extract of the leaves, a teaspoonful 
three times daily. The patient had been confined the year before with 
her first child, but had no milk for it, though her health was good, and 
measures were employed, as friction and fomentations, to stimulate the 
secretion. The ricinus was prescribed the fourth clay after her confine- 
ment with the second child, when there were no signs of secretion, and 
the breasts w r ere small. " About two hours after the poultice was applied, 
and the first dose taken, she experienced a strange sensation in the breasts, 
and this increased after each dose of the medicine. The poultice was not 



48 LACTATION. 

renewed, but the extract was continued for three days, after which lacta- 
tion was perfectly successful." So far then observations appear to show 
that ricinus is one of the most efficient galactogogues which we possess 
among medicinal agents ; but all other modes of increasing the milk are 
probably less effectual than that which is natural, namely, suckling. 

In the treatment of galactorrhoea the object to be attained should be 
kept in view. There are medicines which cure this affection by diminish- 
ing the amount of milk. Belladonna, iodide of potassium, and colchicum 
are antigalactics. It is proper to use them in case of weaning or of death 
of the infant. They not only reduce the quantity of milk, but, continued, 
may prevent its secretion. They are employed not to benefit the infant, 
but the mother. 

On the other hand, if it is our purpose to prevent the oozing of milk in 
order to save it for the infant, or, if it is abundant and watery, to diminish 
somewhat its quantity and improve its quality, the treatment should be 
different. Iron, in cases of galactorrhoea, in which the condition of the 
system appears to incficate the need of it, will diminish the quantity of 
milk and render it richer. It is by many regarded as an antigalactic, and 
given long it might reduce too much the amount of the secretion, and even 
necessitate weaning. Its use should be discontinued if no more than the 
normal amount of milk is secreted. 

In most cases of true galactorrhoea the pathological state is that of 
weakness and relaxation of the tissues. The fault is not excessive secretion 
of milk so much as its non-retention, and the medicines which are the 
most useful to correct this state of the system and of the breasts are the 
vegetable tonics and astringents. If galactorrhoea occur in those who 
have an habitual discharge, and it appears to be due to the same cause 
which produces that discharge, and there are no evidences of weakness, 
laxative medicines and other derivatives may be employed. But such 
cases are not common. Nux vomica has been recommended in galactor- 
rhoea, in the belief that it diminishes the relaxation of the orifices of the 
lactiferous tubes. 

Local treatment in this affection is important. A cloth wrung out of 
cold water should be occasionally applied around the nipple, and removed 
as it becomes warm. Solutions of tannin or alum are likewise useful. 
Collodion applied around the nipple, by the contraction which it pro- 
duces, diminishes the orifices of the ducts, and thus aids in the retention 
of the milk. 



SELECTION OF A WET-NURSE. 49 



CHAPTER Y. 

SELECTION OF A WET-NURSE. 

In the cities cases are frequent in which mothers, with all possible care 
or endeavor, find themselves unable to suckle their infants. Their health 
is too poor, or the milk possesses the properties of colostrum, or it is no 
longer secreted, on account of nervous excitement, or exhaustion, or in- 
flammation of the breasts. The number of such cases in the city would 
surprise physicians who are familiar only with the healthy and robust 
mothers of the country. The infant thus deprived of the mother's milk 
should, if practicable, be furnished a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, and 
is a duty of great responsibility. It is better to select one between the 
ages of twenty and thirty years, and one who has suckled an infant pre- 
viously. A wet-nurse between the ages of twenty and thirty is usually 
more active, cheerful, and conciliatory than one of a more advanced age, 
and her milk is more apt to be abundant and nutritious. Those who have 
previously suckled and had charge of infants are obviously more compe- 
tent to serve as wet-nurse than are primiparae. The milk of a wet-nurse, 
whose infant is under the age of six months, will ordinarily agree with a 
new-born infant. If above that age, it sometimes agrees, but often does 
not. 

The most difficult and responsible task imposed on the physician in the 
selection of a nurse, is to ascertain the exact condition of her health, and 
the quantity and quality of her milk. Constitutional syphilis is common 
in the class of women who present themselves for wet-nursing ; it is often 
latent, or its symptoms are easily concealed, and it is communicable by 
lactation. The virus may be received by the infant from fissures or ex- 
coriations of the nipple. The nursling tainted by syphilis may, on the 
other hand, communicate the disease to the nurse through the same source. 
It is not fully ascertained whether the syphilitic virus may be conveyed to 
the infant by the milk. But the cases which have accumulated in the 
records of medicine are numerous, in which infants born of healthy parents 
have been fully syphilized by lactation from diseased nurses (see article 
Syphilis). These infants have sometimes led a short and miserable exist- 
ence, and have occasionally increased the misery of the household by im- 
parting the disease to others. The duty is, therefore, imperative on the 
part of the physician to examine carefully the wet-nurse, in reference to 
4 



50 SELECTION OF A WET-NURSE. 

any evidences of the syphilitic taint. Acquainted with the symptoms of 
syphilis, he may usually, by shrewd questioning and by careful examina- 
tion of the present appearance and condition of the woman, ascertain with 
considerable certainty whether her system has ever been infected. Refer- 
ences should also be obtained and consulted, and, if practicable, the phy- 
sician who has attended her be communicated with. 

There are, also, among the women who present themselves for wet- 
nursing in the cities, many of a scrofulous habit, and many who possess an 
hereditary tendency to tuberculosis, if indeed they do not already have 
the incipient disease. Such applicants should be rejected, on account of 
the poverty of their milk and the probability that they will not be able to 
endure the debilitating effect of lactation. 

The milk should be examined, in order to ascertain its richness and 
quantity, and whether it contains colostrum. If there is colostrum after 
the eighth day, it is probable that there is some fault in the health or diges- 
tion of the wet-nurse, and that her milk may disagree with the infant. 
It is not necessary that the breast should be large, in order to furnish a 
sufficient quantity of milk, since, as has been already stated, in some the 
secretory function is active during the time of each nursing, so that, 
although the breasts are of moderate size, a sufficient amount of milk is 
furnished. The nipples should be well formed and prominent, and prefer- 
ence is to be given to those wet-nurses in whom bloodvessels are seen 
ramifying over the breasts. 

By examination of the milk, its degree of richness can be readily ascer- 
tained. A quantity of it should be placed in a test-tube, and the cream, 
which rises to the top, indicates, approximately, the character of the milk. 
Good milk furnishes three per cent, of cream, and the caseum and sugar 
usually correspond in quantity with the cream. An instrument has been 
invented, called the lactometer, by which the exact amount of the cream 
can be ascertained. It is simply a tube graded into 100 divisions. It is 
placed upright, and filled with milk, and the number of divisions occupied 
by the cream indicates its proportion in 100 parts. The lactoscope is 
another instrument employed for the purpose of ascertaining the richness 
of the milk. It consists of two concentric tubes, which move upon each 
other. Milk which we wish to examine is poured within the tubes suffi- 
cient to obscure a light viewed through it, three feet distant. The column 
of milk is then diminished, till the light begins to be visible. The size of 
the column indicates the degree of opacity and the richness. The lacto- 
scope was invented by M^. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the richness of 
cow's milk, and it would equally answer for the breast-milk. A vessel 
holding about one ounce, and containing a graduated enamel slab, passing 
diagonally from above downwards, is filled with milk. It is then covered 
with a glass slide carried over it in such a way as to exclude bubbles. 



EXAMINATION OF THE MILE. 51 

The number of degrees which can be read, indicates the character of the 
milk, as regards its richness. 

Examination of the milk with the microscope not only enables us to de- 
termine whether there are abnormal corpuscles or granular elements, but 
also its richness. It should be examined before the cream has separated. 
Oil-globules of small size, and few, indicate poverty of the milk ; very large 
oil-globules are said to indicate milk which is apt to be indigestible, espe- 
cially in feeble infants. Such are the free globules of the colostrum. 
Numerous oil-globules of medium size indicate nutritious milk. Vogel, 
in 1850, made the discovery of vibriones in human milk. The fact is 
established that these animalcules may be generated in the milk within 
the breast, though such cases are not frequent. Dr. Gibb describes a case 
which he met. {Ranking' s Abstract, vol. xxxiv.) An infant, 7 weeks old, 
wet-nursed by its mother, who had the appearance of perfect health, was, 
nevertheless, ill-nourished and emaciated. It had no diarrhoea or other 
apparent disease, and the milk was therefore examined. Vibriones baculi 
were found in the milk immediately after it was obtained from the breast. 
The milk had the usual amount of cream, and seemed to the naked eye of 
good quality. According to Dr. Gibb, two genera of microscopic organisms 
occur in the milk, namely, vibriones and monads. It is believed that the 
monads occur in consequence of fermentation of the sugar and the produc- 
tion of lactic acid. Vogel also attributed the production of the vibriones 
to fermentation occurring in consequence of heat and congestion of the 
breast, connected with sexual excitement. This explanation is probably 
not correct, because vibriones sometimes occur when there is no unusual 
heat of breast, and no evidence of fermentation. The fact that such or- 
ganisms may occur in milk which seems of good quality to the naked eye, 
affords additional proof of the usefulness of the microscope in the selection 
of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after delivery. The re-establishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, 
and perhaps less digestible ; in other women it does not sensibly affect the 
character of the fluid or its quantity. In the selection of a wet-nurse, 
then, preference should be given to one who does not have the periodical 
sickness, but if she is already employed, and gives satisfaction, the reap- 
pearance of the catamenia does not indicate the need of the change of 
nurse, unless the digestion of the infant is disordered, or its nutrition is 
impaired. 

In the selection of a wet-nurse attention should also be given to her 
mental and moral traits. Cheerfulness, affection, veracity, and a proper 
appreciation of the responsibility of her situation, enhance greatly the 
value of a wet-nurse. Not less important are habits of temperance and 
cleanliness. I could cite cases of the most melancholy results from 



52 COURSE OF LACTATION — WEANING. 

the absence of these traits. In one case idiocy resulted from an infant 
falling upon the pavement from the arms of a reckless or intemperate 
wet-nurse. 

In most cases the mode of examination indicated above suffices to show 
the character of a wet-nurse, so far as her health and milk are concerned. 
It should be borne in mind, however, that the microscope does not always 
reveal deleterious properties in the milk. Elements which are in a state 
of solution, and are invisible, may occur in excess, so as to impair the 
quality of the milk an(l render it indigestible. The following case, in 
which the saline ingredients seem to have been in excess, is related by 
Dr. Hartmann (British and Foreign Medical Review, vol. xii.) : "An 
infant, whose mother was in good health and had borne several children, 
exhibited a healthy appearance for the first five weeks after birth. The 
alvine evacuations then became copious, fluid, and discolored, and the 
child lost flesh and strength. After the usual remedies had been vainly 
administered for a fortnight, the mother remarked that the child did not 
take the right breast willingly, and so much did the unwillingness in- 
crease, that at length the mere application of the nipple to the child's lips 
occasioned loud crying. On examination it was found that the milk of 
the right breast had a distinctly saline taste ; whereas the milk of the 
opposite breast was of the ordinary sweetness ; no difference of consistence 
or color was discoverable. From that time the child was only allowed to 
nurse the left breast, and in a few days all diarrhoea and sickliness of ap- 
pearance vanished." In this case there was no appreciable disease of the 
breast, although its secretion was perverted. The deleterious character of 
the milk was discovered, not by any change in its appearance, but by the 
taste. 



CHAPTER VI. 

COURSE OF LACTATION— WEANING. 

Regularity in nursing is required. During the first week or two 
after birth the infant may be applied very often to the breast, when awake, 
but subsequently, it should nurse about every two hours during the day, 
and every three or four hours during the night. Still, as M. Donne has 
said, mathematical exactness in this matter would be ridiculous. Quiet, 
natural sleep of a well-nourished infant should not be interrupted in order 
to give it the breast, unless the sleep be unusually protracted. It will 
usually awaken when the system requires more nutriment. Ill-nourished 
infants, according to my observations, sleep but little until they become 



COURSE OF LACTATION — WEANING. 53 

much prostrated, when they are drowsy, in consequence of passive con- 
gestion of the brain. This drowsiness is evidently a pathological symp- 
tom. It shows the need of increased nutrition. It is due to scantiness of 
milk, or milk of poor quality, and the infant should be aroused frequently 
for the purpose of giving it nutriment or even stimulants. 

As the infant grows older the stomach receives a larger amount of milk, 
and it should nurse less frequently. The breast-milk is sufficient for its 
nutrition till the age of six or eight months, provided it is abundant and 
of good quality. If the mother be strong, and experience no exhaustion 
from suckling, the infant, therefore, need receive no other nutriment till 
that age. 

Many mothers, however, by the third or fourth month of lactation, find 
that they have not sufficient milk to meet the wants of the infant. The 
constant drain upon their systems sensibly impairs their health. In such 
cases it is proper to commence with a little feeding from the spoon or 
bottle, and increase the quantity given as the infant grows older. Great 
care is, however, requisite in the preparation of food for so young an 
infant, whose digestive organs are still feeble and easily deranged. In the 
country, where diarrhceal affections and the so-called gastric derangements 
are not frequent, the danger from artificial feeding is less than in the 
city, and in the cool months in the city the danger is less than in the 
summer season. Infants of the city, between the months of May and 
October, have a strong predisposition to diarrhoeal attacks, the result of 
anti-hygienic influences which surround them. Errors of diet in their 
case readily provoke disease or derangement of the digestive organs, often 
of a severe and dangerous form. Moreover, experience has shown that 
these infants, if fed with the bottle, however carefully, during the period 
when nature designed that they should be nourished by lactation, very 
commonly are affected in the hot months with more or less vomiting and 
diarrhoea, followed by emaciation and other evidences of mal-nutrition. 
Therefore, an exception must be made, in case of the city infant, as re- 
gards the commencement of artificial feeding. If it is under the age of 
one year, it should be nourished exclusively, or almost exclusively, at the 
breast during' the hot months, when practicable, even if the mother- suffers 
somewhat in her health from the constant drain upon her system. "'The 
infant should, however, receive the amount of nutriment which it requires, 
and, if there is not sufficient breast-milk, it will be necessary to supply the 
deficiency by artificial feeding. The reader is referred to Chapter VII. 
for facts relating to the subjects of artificial feeding. 

No fixed rule can be stated in regard to the time when it is proper to 
allow artificial food in addition to the breast-milk. While robust mothers 
with abundant milk can satisfy their infants till the age of six or seven 
months, many begin to feel the drain upon their systems and have an 
insufficient supply by the third or fourth month, and it is necessary to 



54 COURSE OF LACTATION — WEANING. 

supplement the nursing by the use of artificial food, a smaller or larger 
quantity as the case may require. The deficiency may be supplied by the 
use of cow's or goat's milk, Liebig's food especially for young infants, 
barley, or rice flour, Ridge's food, or wheat flour prepared by long boiling, 
as recommended in Chapter VII. At six months also, or even at four or 
five months, if the infant appear anasmic and ill-nourished, it may be 
allowed occasionally one or two teaspoonfuls of beef-juice expressed from 
slightly boiled beef two or three times daily. At the age of eight months 
semi-liquid food may be given. Pap, prepared with stale bread or a 
rolled soda-cracker, may also be given once or twice daily, between the 
times of nursing, and occasionally beef-tea or chicken-broth, thickened 
with cracker or bread, is taken with relish, and if well prepared and given 
no oftener than once or twice a day, it is commonly readily digested while it 
is highly nutritious. If the quantity of breast-milk diminishes, as it often 
does, towards the close of the first year, artificial food should be given 
oftener, so as to supply the deficiency. Solid food requires considerable 
development of the digestive organs for its ready assimilation. It should 
not, therefore, be given till the close, or near the close, of the first year. 

Weaning ought to take place, as a rule, between the ages of twelve and 
fifteen months. It is well, if the mother's health is good and her milk is 
sufficient, to defer weaning till the canine teeth appear. The infant then, 
possessing sixteen teeth, is able to masticate the softer kinds of solid food. 
Weaning should be gradual. Mothers often speak of weaning on a cer- 
tain day. They have given but little artificial food, and have suckled at 
regular intervals, till at a fixed time they have denied the breast alto- 
gether. This abrupt change of diet should be discouraged. It should 
only be recommended under peculiar circumstances. It is apt to derange 
the digestive organs, and it causes fretfulness and sleeplessness on the part 
of the infant for a week or more. Weaning should commence by feeding 
with the spoon, a little oftener through the day, and nursing less, and by 
discontinuing the practice of suckling at night. The infant tolerates this 
gradual change of diet, w T hile it rebels against sudden weaning, and by its 
fretfulness increases greatly the care and trouble of the mother. The 
infant in the city should not be weaned in warm weather, nor within a 
month immediately preceding it. If the mother's health fail, or her milk 
become deficient in the summer months, so that she cannot continue 
suckling, the infant should be sent immediately to the country, or a wet- 
nurse be employed. Many infants are sacrificed in consequence of igno- 
rance of the danger of weaning under the circumstances mentioned. 
Severe diarrhcEa, inflammatory or non-inflammatory, is apt to result. 
This subject will be considered elsewhere. 



ARTIFICIAL FEEDING, 



55 



CHAPTER VII. 



ARTIFICIAL FEEDING. 



Occasionally the mother is unable to suckle her infant, and a hired 
wet-nurse cannot be or is not obtained. Artificial feeding is then neces- 
sary. In the large cities, if I may judge from our New York experience, 
this mode of alimentation for young infants should always be discouraged. 
It generally ends in death, preceded by evidences of faulty nutrition. A 
considerable proportion of those nourished in this manner thrive during 
the cool months, but on the approach of the warm season they are the first 
to be affected with diarrhoea and other symptoms indicating derangement 
of the digestive function. In my opinion, based on a pretty extended ob- 
servation, more than half of the New York spoon-fed infants, who enter 
the summer months, die before the return of cool weather, unless saved by 
removal to the country. In the country, and in the small inland cities, 
the results of artificial feeding are much more favorable. The majority 
live, and in elevated farming sections on account of the salubrity of the 
air, and the facility with which milk, fresh and of the best quality, is ob- 
tained, artificial feeding appears to be nearly as favorable as wet-nursing. 

Young infants, fed by the hand, obviously require food prepared so as 
to resemble as closely as possible the human milk. The basis of such food 
must, therefore, be the milk of some animal. The following table, pre- 
pared by MM. Vernois and Becquerel, gives the proportion of the ingre- 
dients of human milk, and the milk of the four domestic animals which 
is most easily obtained and most frequently employed as food : — 



Composition of Milk. 





Specific 
gravity. 


100 parts 


contain 


The solid components cons 


st of 




Fluids. 


Solids. 


Sugar. 


Butter. 


Casein and 

extractive 

matters. 


Salts. 


Man .... 
Cow .... 
Ass .... 

Goat . . 
Ewe .... 


1032.67 
1033.38 
1034.57 
1033.53 

1040.98 


889.08 
864.06 
890.12 
844.90 
832.32 


110.92 
135.94 
109.88 
155.10 
167.68 


43.64 
38.03 
50.46 
36.91 
39.43 


26.66 
36.12 
18.53 

56.87 
54.31 


39.24 
55.15 
35.65 
55.14 

69.78 


1.38 
6.64 
5.24 
6.18 
7.16 



56 ARTIFICIAL FEEDING. 

Cow's milk is most readily obtained, and is commonly used as a substi- 
tute for human milk, compared with which it contains less water and sugar, 
but more butter, casein, and salts. Its composition, however, varies con- 
siderably according to the food of the cow and other circumstances. The 
variations in the milk of the cow, according to the nature of its food, have 
been considered in a preceding chapter. It has been stated, also, that the 
milk first obtained in milking is most watery, since it is longer secreted 
than the last milk, or the " stripping." The stall-fed cow gives acid milk, 
while the cow grazing in a pasture gives milk that is alkaline. Again, 
the milk in the first months after calving is richer than after the lapse of 
several months. 

It is obvious from the above facts that the analysis of different speci- 
mens of cow's milk must differ greatly, and the same is true of the milk of 
the goat and ass, and probably of the ewe. In fact, different samples of 
the milk of the same animal may differ more from each other, in their 
chemical character, than the average milk of one animal from that of 
another. 

The milk of the goat and that of the ass have been recommended as 
food for infants in preference to cow's milk, on the ground, as is alleged, 
that they more nearly resemble human milk. But by reference to the fore- 
going table it will be seen that more importance has been attached to this 
supposed resemblance than the facts justified. Neither the milk of the ass 
nor goat, so far as its chemical character is concerned, would seem to pos- 
sess any advantages over cow's milk. The ass's milk is procured with 
difficulty, and is seldom used. An objection to goat's milk is the unpleasant 
odor which it often possesses, due to the presence of hircic acid. It is 
stated, however, by Parmentier, that this odor is only noticed in the milk 
of goats that have horns. An important advantage, in the city, in the use 
of goat's milk, is that the animal can be kept at little expense, so that even 
poor families who are not able to purchase and feed a cow, can generally 
possess a goat from which fresh milk can be obtained at any time. Pre- 
ference is to be given to goat's milk, when fresh, over cow's milk brought 
from the country, perhaps watered on the way, and several hours old 
when received. If, however, as both chemical analysis and experience 
show, goat's milk is no better as food for infants than cow's milk when 
fresh and from healthy cows, the latter must continue in common use for 
this purpose. 

Milk used for infants should always be alkaline. If it is acid, as shown 
by the proper test, it should be rejected ; or, if there is none better, should 
be rendered alkaline by the addition of lime-water or carbonate of soda. 
The nurse should test the milk at different periods through the day, and 
be taught to make the necessary addition. M. Donne prefers the first 
milking, when it is possible to obtain it. This contains a smaller propor- 
tion of solid elements than the average milk, bears a closer resemblance 



ARTIFICIAL FEEDIXG. 57 

in its chemical character to human milk, and requires but little dilution. 
The upper third of the milk, after it has stood two or three hours, is also 
preferable, as the casein, which is digested with more difficulty than the 
other elements, has a high specific gravity, and tends to settle towards the 
bottom. If the infant is under the age of two or three months, the milk 
should be diluted with one-fourth its quantity of water. After the age of 
four months it requires no dilution. It should always be given at a uni- 
form temperature, namely, a little warmer than the body. Employed 
habitually too hot or too cold, it is apt to cause stomatitis, if not more 
serious disease of the digestive organs. 

A little pulverized sugar of milk, which is now kept in the shops of the 
city, and is slowly soluble, may be dissolved in water, and added to the 
milk. One drachm of the sugar is sufficient for five or six ounces of the 
milk. An alkali taken with cow's milk retards the coagulation of casein 
in the stomach, and tends to prevent the formation of large and thick 
curds in this organ, which are with difficulty digested, and are apt to give 
rise to gastric or gastro-intestinal derangement. If, therefore, the child 
vomits such curds, or passes fragments of them in the stools, or if the 
stools are acid, lime-water may be added, or the carbonate of soda, as 
recommended by Yogel, who dissolves one drachm of the carbonate in six 
ounces of water, and adds a teaspoonful to the milk at each meal. 

It has been customary in families to give bottle-fed infants various kinds 
of farinaceous food, as arrowroot, wheat, rice, and barley-flour in addition 
to the milk. But infants, prior to the age of four months, are able to di- 
gest only a small quantity of starch, for the glands which secrete the fluid 
by which starch is digested, namely, the salivary and pancreatic, are very 
small, almost rudimentary prior to the fourth month. Certain glands, 
whose functions are important in the life of the individual, are small, and 
have but little activity in the first weeks or months of life. Such are the 
lachrymal and intestinal glands in addition to the salivary and pancreatic. 
After the third month tears appear, and the quantity of saliva which pre- 
viously was very small is more abundant, and it increases as the child 
grows older. After the third or fourth month not only is there a more 
rapid growth of the salivary glands and pancreas than previously, but also 
probably a greater functional activity. In a recent monograph relating 
to Infant Diet, written by Prof. A. Jacobi, and revised, enlarged, and 
adapted to popular reading by Dr. Mary Putnam Jacobi, it is stated that 
the parotid glands which combined weigh, at fifteen months, 80 grains, 
and 120 at two years, weigh but 34 grains at the age of one month. In 
several instances we weighed the pancreas taken from the bodies of infants 
who had died under the age of six months in the New York Infant Asylum. 
The weight was very different in those whose ages were about the same ; 
in several under the age of four months it was less than one drachm, and 
in some more than one drachm ; but in no instance did it reach two 



58 ARTIFICIAL FEEDING. 

drachms. Now it is evident, since the parotids and pancreas chiefly 
secrete the liquid by which starch is digested, for the submaxillary and 
sublingual glands are comparatively insignificant, that those kinds of food 
which consist largely of starch are innutritious, and therefore unsuitable 
for very young babies (see paper by Sonsino, of Pisa, in London Practi- 
tioner, Sept. 1872). 

If, however, we convert the starch, or a considerable part of it, into 
grape-sugar, or glucose, and dextrin, we have a food which is more easily 
digested, so that it can safely be given to infants under the age of three 
months. The late Baron Liebig, who devoted considerable time in the 
last years of his life to the study of the food of infants, prepared such an 
article, widely and favorably known in both continents as Liebig's food. 
Hawley's Liebig's food, made by Dr. Hawley, of Brooklyn, has been in 
the shops for some years. More recently, Liebig's food made by Mr. 
Horlick, of Chicago, and that by Mr. Mellin, of London, which are nearly 
identical, have come into use. Being carefully prepared, according to 
Liebig's formula, by chemists fully competent, they possess certain advan- 
tages, such as quick and easy preparation and a pleasant flavor, and are, 
therefore, highly esteemed by those who have employed them. 

The accompanying statements show us the nature of Liebig's food, and 
the way in which it is made. Starch is transformed into sugar and dex- 
trin, a change which, when farinaceous substances are used in the usual 
way, is effected in the stomach, and thus this organ is relieved from a part 
of the burden of digestion. 

" The following is the best way of preparing this food : Half an ounce 
of wheaten flour, and an equal quantity of malt flour, seven grains and a 
quarter of bicarbonate of potash, and one ounce of water are to be well 
mixed ; five ounces of cow's milk are then to be added, and the whole put 
on a gentle fire. When the mixture begins to thicken, it is removed from 
the fire ; stirred during five minutes ; heated and stirred again, till it be- 
comes quite fluid, and finally made to boil. After the separation of the 
bran by a sieve, it is ready for use. By boiling it for a few minutes, it 
loses all taste of the flour." {Lancet, January 7, 1865 ; Braithwaite's 
Retrospect, July, 1865.) 

This food, according to Liebig, furnishes double the amount of nutriment 
contained in milk, or as he expresses it, is a " double concentration" of that 
secretion. 

Dr. Hassell, in a communication in reference to this food to the London 
Lancet for July 29, 1865, says: " It appears to me that the great merit 
of Liebig's preparation consists in the use of malt flour as a constituent of 
the food ; this, from the diastase contained in it, exercises, when the fluid 
food or soup is properly prepared, a most remarkable influence upon the 
starch, quickly transforming it into dextrin and sugar, so that in the course 



ARTIFICIAL FEEDING. 59 

of a few minutes the food, from being thick and sugarless, becomes com- 
paratively thin and sweet." 

. . . " Correct and ingenious as are the principles upon which this food 
has been designed, yet the directions given for its preparations are certainly 
open to considerable improvement. Thus, Liebig directs that the malt 
should be ground in a common coffee-mill, and the coarse powder passed 
through a sieve. This necessitates the subsequent straining of the food, a 
tedious operation, in order to remove the bran and remaining particles of 
husk. And further, that the food should be put upon a gentle fire previous 
to its being finally boiled. Now, a gentle heat may mean almost any 
temperature nearly up to the boiling-point ; and since the action of the 
diastase is destroyed at about 150° F., the temperature should never be 
allowed to exceed that degree. 

" I recommend, therefore, that the malt should be well freed from husk, 
and finely ground ; that the wheat flour should be lightly baked ; and 
finally, that a thermometer should be employed in the preparation of the 
food. Indeed, in some samples recently submitted to me by Messrs. Sa- 
vory and Moore, I find that the first two points have been attended to, and 
that they use malt freed from husk and finely ground, and the wheat flour 
baked. 

" The effect of baking the wheat flour is to partially cook the starch 
entering into its composition, so that less heat is required in the prepara- 
tion of the liquid food. I find that a temperature ranging between 140° 
and 148° is amply sufficient to effect the complete transformation and solu- 
tion of the starch-corpuscles, and, indeed, to cook the food sufficiently." 

Dr. James S. Hawley, who has given much attention to the prepara- 
tion of Liebig's food, and who now furnishes the market with it, says : 
"The principal objection which has been urged against Liebig's food is the 
difficulty of its preparation. This objection certainly did lie against the 
process recommended by its author, and against many of the directions 
since proposed. But . . . the simplest form of cooking is all that is 
requisite. This consists in mixing the dry food, properly compounded, 
with milk or water (better milk), and slowly bringing it to a boil with 
frequent stirring ; or heating it until it begins to thicken, then remove it 
from the fire and stir until it grows thin, and repeat this process two or 
three times. At the close of the process it will be quite thin and sweet. 
No food can be cooked in a simpler manner than this. This dissolving of 
the thick hydrated starch is itself the evidence of the transformation of 
amylum into glucose. It is not claimed, that by this simple method, all 
the starch is converted, but that its percentage is very greatly diminished, 
sufficiently so to afford abundant assimilable nutriment to the infant, and 
also to avoid the dangers and inconveniences arising from the presence of 
indigestible matter in the intestines." 

In Ridge's food, although the manner in which it is made is kept secret, 



60 BATHS — CLOTHING, 

I suspect that a partial change of the starch into glucose has been effected. 
We are informed that it is made from wheat Hour, and it certainly agrees 
with young infants, as I have many times observed. It contains, how- 
ever, considerable starch, as is shown by the iodine test. Again, if we 
crowd snugly in a small muslin bag one to two pounds of the best wheat 
flour, boil it forty-eight hours in water sufficient to cover it, and then 
when it dries grate the flour from it, we obtain what closely resembles 
Ridge's food. These kinds of flour have been employed in the New York 
Infant Asylum with a satisfactory result, but the preference is given to 
Ridge's food, which seems to agree with the largest number. But for 
infants under the age of three or four months, Liebig's food is obviously 
to be preferred for the physiological reason stated above. 

In the first half year it is most convenient and is otherwise preferable 
to employ the nursing-bottle, after which the infant may be feci with a 
spoon, or taught to drink from a cup. The bottle and tip, when not in 
use, should be placed in a bowl of cold water containing a little bicar- 
bonate of soda, one teaspoonful to the pint. 

The physician should positively forbid the use of sugar teats and various 
sweetened admixtures which nurses are so apt to employ, as they tend to 
produce the common forms of stomatitis, and, if much employed, even 
indigestion and diarrhoea. 

Between the ages of one and two years the teeth have become suffi- 
ciently developed for the mastication of light food. Tender and finely cut 
meat, potato baked and mashed, bread and butter, and even certain fruits 
carefully selected, may then be allowed. After the age of two years less 
rigid surveillance of the food is required, but the variety is sufficient if 
all dishes except the most bland and unirritating are excluded till after 
the first years of childhood. 



CHAPTER VIII. 

BATHS— CLOTHING. 

Daily ablution of the infant conduces to its comfort and health. If 
under the age of two months, it should be bathed daily in water of about 
the temperature of 92°. As it grows older the temperature should be 
gradually reduced, a bath at 88° to 90° being proper for an infant be- 
tween the ages of three and six months, and one at 86° for an infant 
between six and twelve months. In the second and third years the tem- 
perature of the bath should be about 84°. After the bath, which should 
continue from five to ten minutes, the surface should be gently rubbed 



BATHS — CLOTHING. 61 

with a soft towel to produce reaction and a glow of the skin, which would 
prevent danger of taking cold. 

The clothing of children, especially in our variable climate of the north, 
is a matter of importance, and one in regard to which the parents often 
require instruction. It may be stated, as a rule, that the chest and abdo- 
men of the infant should be so covered with flannel that there is no danger 
of producing chilliness by a sudden reduction of the external temperature 
or exposure to a current of air. By this precaution many cases of laryn- 
gitis, bronchitis, and diarrhoea! affections, now so common in infancy, 
mio-ht be avoided. In winter the flannel should be thick, and in the sum- 
mer thin. Even in the hottest weather the abdomen should have a light 
flannel covering, which increases the comfort, if the surface is in the nor- 
mal state. If lichen, which is not uncommon in the warm months, ap- 
pear upon the surface, I would not remove the flannel, but place under it 
linen or soft muslin. 

The popular idea that children may be hardened by exposure to the 
weather in scanty clothing, and by being bathed, even at the most tender 
age, in water at so low a temperature as to produce chilliness, cannot be 
too strongly combated. The hygienic management of the child should 
always be such as insures present comfort. If it do not, if it is regarded 
with aversion and dread by the child, the method is wrong. 

The dress should always be so loose as to allow free movements, and 
not embarrass in the least any of the functions. This is a matter which 
is left too much to the discretion and intelligence of the nurse, who is 
usually so ignorant of the important facts in physiology that she unwit- 
tingly, and with the best intentions, injures her charge. I have often 
interposed to loosen the dress of the new-born, which was so tight as to 
sensibly embarrass respiration ; and one case has been reported to me in 
which it appeared that death resulted from this cause. Infants, especially, 
who are so liable to pulmonary collapse and intestinal hernias, should have 
loose covering of both chest and abdomen. 

The feet of children should always be warm. Infants require flannel 
stockings, thick or thin, according to the season. Care should be taken 
that the shoes produce no compression, and they should be exchanged for 
those of a larger size as often as is required by the growth of the feet. 
Deformity of the feet or toes, ingrowing toe-nail, and induration of the 
skin, can sometimes be traced back to tightness of a shoe in childhood. 

Physicians are so well aware of the importance of domiciliary cleanli- 
ness and ventilation, of the free admission into the nursery of solar light, 
and of the importance of outdoor exercise as a means of invigorating the 
system and promoting healthy functional activity, that nothing need be 
stated in reference to these subjects in this connection. 



62 APNCEA NEONATORUM 



CHAPTER IX. 

ACCIDENTS AND AILMENTS INCIDENTAL TO THE BIRTH OF THE 
INFANT, AND DETACHMENT OF THE CORD. 

Apncea (Asphyxia) Neonatorum. 

In the healthy infant, born under favorable circumstances, the two 
important functions of life, respiration and circulation, are established 
within the first minute. But it not infrequently happens! in consequence 
of some unfavorable circumstance, that the heart and lungs cease to act, 
and the infant lies motionless as one dead. Sometimes in these cases an 
occasional pulsation of the heart can be detected when the fingers press 
under the left ribs, but there is no respiration. According to the nature 
of the cause, the surface is exsanguine or cyanotic and livid. 

Causes. — These are various. The fault may be partly in the infant ; 
it may be feeble in its development ; but the common causes are compres- 
sion of the cord during birth, from breech presentation or otherwise, 
powerful, frequent, and long-continued uterine contractions, often induced 
by ergot, but sometimes occurring normally, which compress the placenta, 
and consequently obstruct the foetal circulation ; detachment of the pla- 
centa before birth, and protracted labor, from pelvic malformation or 
otherwise, even when there is no unusual severity of the pains. 

Treatment Obviously the treatment must be prompt. Mucus should 

be removed from the mouth and fauces with the finger, and except in those 
cases in which there has been placental hemorrhage or anosmia from other 
causes, as exhibited by pallor of the surface, a few drops of blood should 
be allowed to run from the cut extremity of the cord. The flow induced 
aids in establishing the circulation, and, in the large proportion of cases in 
which there is congestion of the internal organs, gives partial relief to it. 
Brisk rubbing of the body, slapping the buttocks, blowing in the face, 
sprinkling w T ater upon it, alternately transferring the body from a tub of 
hot to cold water, may be tried in quick succession, and, if there are no 
signs of returning animation, no time should be lost in resorting to arti- 
ficial respiration. 

The child should be placed on its side upon the edge of a table, with a 
blanket underneath it, and the head in such a position that the epiglottis 
falls forward ; a towel or napkin should be placed over its face, having a 
hole of sufficient size to blow through corresponding with its mouth. The 
physician compressing firmly the epigastrium with his thumb, blows a 



APNCEA NEONATORUM. 63 

full breath through the hole. A little of the air, notwithstanding the 
compression, enters the stomach, some may escape by the nostrils, and the 
rest enters the lungs. Immediately, the hand passing from the epigas- 
trium to the thorax, compresses it gently though with sufficient force to 
produce expiration. This should be repeated six or eight times per minute. 
The action of the heart, previously slow, becomes quicker by the artificial 
respiration. I have been able to produce pulsations by this method when 
the heart had ceased to beat for a considerable time, and death, to all 
appearance, had occurred. Some recommend placing the infant on the 
right side, on account of the position of the valve between the auricles, 
but I think it is better to change it from one side to the other, in order to 
prevent congestions, which are so apt to occur when the circulation is 
imperfect. The circulation always commences sooner than respiration. 
The first respirations are mere gasps, not more than one or two per minute 
in cases of decided asphyxia, but as they become more frequent they are 
also deeper. 

Artificial respiration should be continued fifteen or twenty minutes in 
cases in which no action of the heart can be detected by pressing the 
fingers under the ribs, when, if there are no signs of returning animation, 
the case is hopeless. If there is any pulsation, however feeble, we should 
not cease in the attempt at resuscitation. Some prefer insufflation through 
a tube (as the segment of a catheter) introduced into the larynx, and pres- 
sure upon the thyroid cartilage so as to close the pharynx, instead of upon 
the epigastrium. The principle of treatment is similar, but the mode 
which I have recommended above I have found successful beyond expec- 
tation. Thus, in one case in my practice in which pulsation in the umbilical 
cord had ceased from ten to fifteen minutes before birth in consequence of 
its prolapse, I employed artificial respiration nearly a quarter of an hour 
before there was any appreciable pulsation, but by perseverance the circu- 
latory and respiratory functions were fully re-established, and the child 
lived and was vigorous. When respiration commences insufflation may 
cease, but it is proper to aid the respiratory movements a little longer by 
compressing the thorax after each inspiration. Still, the physician may 
be disappointed in the result. In not a small proportion of cases the res- 
piration continues gasping, and after a few hours, perhaps even a day, 
death ensues. I have made post-mortem examinations of several infants 
who have died under such circumstances, chiefly in the Nursery and 
Child's Hospital, about six from recollection, and have found considerable 
uniformity in the appearance of the viscera. Only a small portion of the 
lungs, sometimes almost none at all, was found inflated, even when the 
cries had for a time been strong, and extravasated blood usually in con- 
siderable quantity lay upon the surface of the brain, evidently having 
escaped from the meningeal vessels, which were in a state of extreme con- 
gestion in consequence of the protracted or difficult birth. Meningeal 



64 CAPUT SUCCEDANEUM. 

apoplexy therefore seems to me the chief cause of the ill-success attending 
our efforts to save those who are so far resuscitated as to be able to breathe. 
Recently, Prof. H. L. Byrd, of Baltimore, has recommended a simple 
mode of resuscitation. The physician places his hands under the middle 
portion of the back of the child, with their ulnar borders in contact, and 
at right angles to the spine. Extending his thumbs, he carries forward 
the two extremities of the trunk by gentle but firm pressure, so that they 
form with each other an angle of about 45° in the diaphragmatic region. 
Then the angle is reversed by carrying backward the shoulders and the 
nates. An assistant may aid by supporting the head. By alternating 
these movements, Prof. Byrd has succeeded in effecting resuscitation when 
other methods had failed, and when so much time had elapsed that the 
case would seem hopeless to most practitioners. The name and position 
of Dr. Byrd commend this method to consideration and trial. (American 
Supplement of Obstet. Joum. of Great Britain and Ireland, 1873.) 

Caput Succedaneum — Cephalsematoma. 

During the birth of the child, extravasation of blood not infrequently 
occurs in the part of the scalp which presents. This results from the pas- 
sive congestion, more or less intense according to the duration of labor and 
severity of the labor-pains, which occurs in the presenting part, whether 
scalp, arm, or breech. Caput succedaneum is the term employed to 
designate the swelling thus caused. Its seat is the loose connective tis- 
sue of the scalp external to the pericranium. The tumor is soft, painless, 
and usually located upon the occiput. It consists partly of extravasated 
blood, but largely of serum which has transuded from the congested ves- 
sels before that degree of congestion was reached, required to effect the 
transudation of the corpuscles. I have repeatedly had an opportunity to 
examine this tumor in stillborn infants brought from the lying-in wards 
attached to the Nursery and Child's Hospital, and have found when it was 
slight that it consisted almost entirely of serum, but ordinarily when dis- 
sected it presented the appearance of a bruise, with a large proportion of 
serum, the blood and serum infiltrating the scalp to a greater or less dis- 
tance beyond the appreciable limits of the tumor. Caput succedaneum 
requires no treatment. As it lies in the loose connective tissue of the scalp, 
its liquid permeates the open connective tissue in every direction, and 
is rapidly absorbed, while the tumor disappears. The subsidence of the 
swelling is usually complete within forty-eight hours. 

Occasionally blood is extravasated under the pericranium, detaching it 
from the bone. This occurs in connection with caput succedaneum, and 
is observed when the latter declines. The tumor thus produced is desig- 
nated cephalsematoma. It is situated upon the occipital or parietal bone, 
near the posterior fontanelle. Its base corresponding with the denuded 



OPHTHALMIA NEONATORUM. 65 

bone is circular or oval, and it rarely crosses a suture. In rare instances 
two cephalrematomata occur, located upon the occipital and one parietal 
or upon both parietal bones. The liquid, being surrounded by the firmly 
attached pericranium, does not escape into the surrounding tissues, as 
occurs in caput succedaneum, and is therefore more permanent. The 
tumor flattens slowly, and does not disappear till after several weeks. At 
the age of six months a slight prominence can sometimes be detected, in- 
dicating the seat of the tumor. As the pericranium elevated by the blood 
does not lose its vitality, it soon begins to produce bone, so that after some 
days a ring of new bone can be detected by the finger surrounding the 
base of the tumor, and on the inside of the detached membrane a layer of 
bone is produced, thin at first and flexible, but gradually approximating 
the old bone, and becoming firmer as absorption occurs. 

Some time since, a specimen was presented by me to the New York 
Pathological Society, showing this accident and the mode of cure. The 
child died about two months after birth, and the blood constituting the 
tumor, which had been in great part absorbed, was completely incased by 
the old bone below and the new thin formation above. The cavity at 
length becomes obliterated, and there only remains some thickening of that 
part of the cranium which corresponds with the location of the tumor. 



CHAPTER X. 

OPHTHALMIA NEONATORUM. 

This disease occurs in two forms, namely, the catarrhal and blenor- 
rhoeal, and there are many cases which are intermediate. 

Causes — These are not the same in all cases. Exposure of the infant's 
eyes soon after birth to a bright light, catching cold, the introduction of 
a little of the vernix caseosa under the eyelids in the first washing, smoke, 
dust, and irritating gases, coming in contact with the eyes are recognized 
causes. Infants living in ill-ventilated and dirty apartments, having un- 
tidy clothing, with faces and bodies seldom properly washed, and attended 
by dirty nurses, are more frequently affected than those in the better walks 
of life, and better cared for. The disease is more prevalent in asylums 
than in private practice, for in the former the anti-hygienic conditions 
which conduce to it more frequently abound. 

Blennorrhoeal ophthalmia has been known to occur during epidemics of 

puerperal fever, probably from the epidemic influence, but a common cause 

is the introduction of a particle of blennorrhoeal matter under the lids, 

during birth, or subsequently by careless handling. But blennorrhoeal 

5 



66 OPHTHALMIA NEONATORUM. 

ophthalmia is in a considerable proportion of cases produced by the action 
of those common non-infectious causes, which have been mentioned above, 
and which in other cases produce a simple catarrhal inflammation. Why 
there is this difference in the effects of these non-specific causes is not 
known. In most cases ophthalmia neonatorum begins soon after birth, 
namely, by the third or fourth day, but it may not begin till in the second 
or third week. 

Symptoms. Blennorrhceal Form. — In the beginning the palpebral con- 
junctiva is observed to be red, a little swollen, and its cutaneous surface 
presenting a faint reddish tinge. The light appears to be painful, and the 
child is fretful and sleeps but little ; but the eye itself has its normal ap- 
pearance. The progress of the disease, however, is rapid, and in twenty- 
four or thirty-six hours there is so much tumefaction that the upper lid 
extends over the lower, and it may be impossible to separate them suffi- 
ciently to obtain a view of the eye. The tumefaction is due to ede- 
matous infiltration. The conjunctiva, both palpebral and ocular, now 
presents a deep red hue, is thickened and swollen, and numerous fine 
granulations appear upon it ; occasionally also flakes of very delicate 
pseudo-membrane can be observed in addition. There is an abundant 
production of pus of a creamy appearance, sometimes tinged with blood, 
which oozes out when the lids are separated. A critical period has now 
arrived, one which may involve the destruction of the cornea unless the 
case is promptly and judiciously treated. Indeed, the gravity of the dis- 
ease relates chiefly to the state of the cornea, which up to the present time, 
notwithstanding the severity of the inflammation and the amount of sur- 
rounding infiltration, has remained transparent and apparently unaffected. 
But within another twenty -four hours the cornea may lose its polish, and 
grayish, opaque spots of softening appear upon it. Soon perforation occurs, 
the aqueous humor escapes, and the iris falls forward, closing the aper- 
ture and preventing further loss of the liquids of the eye. 

I have observed destruction of the cornea and loss of sight chiefly, first, 
in cases of true gonorrhoeal infection, in which there is the maximum 
amount of inflammation and tumefaction, extending even over the malar 
bone and supraorbital ridge, with marked redness and elevation of tem- 
perature of the lids : and, secondly, with a less degree of inflammation in 
those who were highly scrofulous. Attention then to the cornea is all-im- 
portant, since it can usually be saved with proper treatment, although there 
may be so much purulent discharge and oedema that it may be impossible 
to see it for several days. Occasionally the cornea, instead of sloughing, 
becomes infiltrated to a greater or less extent, and ulcerates, but without 
perforation. As the patient recovers, cicatrization occurs. 

The inflammation soon begins to decline. The swelling, heat, and red- 
ness of the lids and conjunctiva, and the granulations, gradually disap- 



OPHTHALMIA NEONATORUM. 67 

pear, and recovery is complete, except so far as the cornea may have been 
injured. 

Catarrhal Form — The inflammation is from the first of a mild grade, 
pertaining chiefly to the palpebral conjunctiva, with but a slight discharge 
of purulent matter, and with little swelling or increase of heat in the lids. 
Attention is directed to the complaint chiefly by the secretion which col- 
lects in the angles of the lids or upon their border. There may be slight 
intolerance of light, and ordinarily minute granulations appear upon the 
inflamed mucous surface. This form of the disease may disappear within 
a few days, or it may be protracted. 

Ophthalmia of the new-born is contagious, sometimes highly so. It 
commences on one side, and, without precautions, commonly within a few 
days extends to the other. 

Treatment As soon as the inflammation occurs, the opposite sound 

eye should be covered with a compress, kept in place by strips of adhesive 
plaster. This eye should be examined, however, once or twice daily, in 
order to detect the commencement of inflammation, and the bandage re- 
applied. 

Catarrhal ophthalmia requires very simple treatment. Frequently 
bathing the lids with lukewarm water, or milk and water, so as to remove 
the secretion from between the lids, suffices in a large proportion of cases. 
In the severer cases, lead-water constantly or frequently applied to the 
exterior of the lids is useful. Among the poor, mothers ordinarily bathe 
the lids with breast-milk, and by this simple treatment effect a cure. If 
the inflammation should not abate soon by this treatment, a mild colly- 
rium of one-fourth grain of nitrate of silver to one ounce of water should 
be applied between the lids and allowed to run under them. 

Blennorrhceal ophthalmia, on the other hand, requires prompt and judi- 
cious management. There is scarcely a disease in which delay is more 
disastrous. 

The frequent removing of the pus is very important, which is confined 
in large quantity underneath the closely compressed lids, and by its pres- 
sure and irritation increases greatly the danger of destruction of the cor- 
nea. Therefore the lids during the height of the inflammation should be 
pressed apart every hour, so as to allow the pus to escape, and the space 
between the lids be freed from pus by a camel-hair pencil or a pledget of 
finely picked lint. Occasionally warm water may be thrown under the 
lids by a small glass syringe, to wash away pus and any flakes of pseudo- 
membrane. Probably two or three drops of carbolic acid to each ounce 
of water would be beneficial, from the - known good effect of this agent on 
suppurating surfaces, but I have never employed it. 

Medicinal applications to the inflamed conjunctiva should, in most cases, 
be mild, but should be frequently applied. It is known that Von Graefe 
recommended the application of nitrate of silver as a caustic ; but this is 



68 OPHTHALMIA NEONATORUM. 

painful and sometimes difficult, for it requires eversion of the lids. I much 
prefer, in the treatment of purulent ophthalmia, the application of a weak 
solution of corrosive sublimate every three hours between and under the 
lids, the pus, so far as practicable, having been first removed by the brush 
and syringe. I employ the following formula, and the result has, in my 
practice, been so favorable that I have not felt justified in trying another : — . 

R. Hyd. chlor. corros. gr. j ; 
Aquae rosae, 3 i i ; 
A quae, ^vj. Misce. 

Still the beneficial result which I have observed from this collyrium, 
was no doubt largely due to the frequent removal of the pus, the import- 
ance of which cannot in my opinion be too highly pressed. In blennor- 
rhoeal ophthalmia, during the active period of the inflammation, with hot 
and swollen lids, a single thickness or two thicknesses of linen, squeezed 
out of cool lead-water, and renewed every two or three minutes when they 
begin to warm, aids materially in subduing the inflammation, every moment 
of which w T hen the lids are much swollen involves danger to the delicate 
cornea. This measure, therefore, which requires diligence on the part of 
the nurse, should be insisted on. As long as the cornea retains its trans- 
parency and polish, the eye is safe, but, as stated above, it is often difficult 
to obtain a view of it for some days. 

The decline of the inflammation is gradual, but generally pretty rapid, 
yet several weeks may elapse before there is full restoration to the normal 
state. When the inflammation begins to abate, and the dangerous tume- 
faction has to a great extent subsided, a collyrium of one-fourth grain of 
nitrate of silver to the ounce will expedite the cure. 

Occasionally granulations remain upon the lids. If they do not dimin- 
ish and disappear when the purulent inflammation has ceased, I would not 
practice excision, as recommended by Vogel, but, having everted the lids, 
apply a solution of nitrate of silver, five or ten grains to the ounce, to the 
granulations, each second day, and immediately wash away the solution 
by a camel-hair pencil with lukewarm water, and apply a little sweet oil 
before the lid is returned. If the granulations do not disappear with this 
treatment, they may be lightly touched with the smooth surface of a crystal 
of sulphate of copper, followed by the application of water and sweet oil. 
By this mode of treatment, employed from the commencement of the in- 
flammation, a large proportion even of the severest cases do well. 



INFLAMMATION OF UMBILICAL VEIN AND ARTERIES. 69 



CHAPTER XI. 

DISEASES OF THE UMBILICUS. 

When properly managed, the cord desiccates and falls off between the 
third and ninth days. The nurse should not be allowed to oil it, which 
she will sometimes do unless forbidden, as this retards desiccation. If the 
dressing of the cord is allowed to remain wet from the urine or otherwise, 
the cord does not desiccate, but decomposes. This is not infrequent in 
poor, intemperate, and slovenly families. The decaying cord is apt to 
produce inflammation of the navel. Some Southern physicians, prior to 
the late Avar, attributed the prevalence of trismus neonatorum among the 
slaves to the lesion of the navel produced by this cause, the trismus being 
then essentially traumatic. 

Inflammation of the Umbilical Vein and Arteries. 

When at birth the cord is ligated, if the child is in its normal state, 
clots form in the umbilical vessels from the navel inwards. Atrophy of 
the vessels follows, and by the twenty-fifth clay they are represented by 
small, firm, fibrous cords. Sometimes, though rarely, a true phlebitis or 
arteritis occurs in these vessels in the first days after birth, due either to 
the low vitality of the child and decomposition of the fibrinous plugs and 
gelatinous substance of the cord, or the entrance into the vessels of puru- 
lent or decaying matter from the fossa of the umbilicus. We are some- 
times able, by pressing along the abdominal walls toward the umbilicus, 
to squeeze out a few drops of the decaying and purulent substance. The 
navel itself is usually inflamed at the same time. This is a very serious 
disease. Pus, with particles of disintegrated fibrin, is apt to pass along 
the vessels and enter the circulation, and, being intercepted in distant parts, 
gives rise to embolismal inflammations. This seemed to be the cause of 
several subcutaneous inflammations, and points of embolismal pneumonitis 
in a new-born infant which I attended in 1868. The infant belonged to a 
family highly scrofulous and prone to scrofulous inflammations. Umbili- 
cal phlebitis and arteritis are said to occur most frequently in lying-in in- 
stitutions during epidemics of puerperal fever. 

Treatment — In the manner already indicated we should attempt 
gently to press out any purulent and decomposing substance from the 
vessels, and the infant should be placed with its abdomen dependent so 
far as it can be done without rendering it uncomfortable, so as to aid in 



70 DISEASES OF THE UMBILICUS. 

the escape of the liquids by gravity. The umbilical fossa should be kept 
clean, and warm water containing a little carbolic acid may be dropped 
upon it several times daily. The abdomen should be covered with a soft 
and warm poultice. 

Inflammation and Ulceration of Umbilicus. 

Inflammation of the umbilicus sometimes occurs in the new-born about 
the time of the detachment of the cord, or soon after. It probably results 
from uncleanliness, or carelessness in the management of the cord, by 
which irritating and decomposing substances remain in the umbilical fossa. 
Sometimes decomposing particles from the cord are the probable irritant. 
This disease is also most apt to occur in cachectic infants, or those of 
scrofulous parentage, whose general condition renders them liable to in- 
flammations. The umbilicus becomes red, slightly swollen, and moist by 
a secretion. Often the inflammation remains two or three days in this 
mild form, receiving no treatment except from the nurse, and disappearing 
by the use of the dusting-powder which she employs. In other instances, 
the inflammation extends over a radius of an inch or even more, the walls 
of the umbilicus become swollen and infiltrated, and ulceration succeeds. 
The ulcer is circular, occupying the site of the naval, and attended by a 
purulent discharge. The inflammation may now gradually abate, and the 
ulcer heal with a cicatrix in place of the umbilicus. But in other in- 
stances, especially if there is a decided cachexia, the ulcer extends in 
breadth and width, till finally, in the worst cases, the peritoneum becomes 
involved, and perforation or peritonitis occurs, with death. 

Under unfavorable hygienic circumstances the blood of the infant being 
vitiated, the ulcer may become gangrenous, or the inflammation may ter- 
minate directly in mortification, without the formation of an ulcer. In 
either case the prognosis is unfavorable. If a dark-brown slough occupies 
the site of the umbilicus, and a sero-sangnineous discharge exudes from 
underneath, the common result is perforation, peritonitis, and death in 
from one to two weeks. 

Treatment Inflammation of the umbilicus, if at all severe, and 

especially when attended by any destruction of the tissues involved, 
rapidly reduces the strength. In such cases four or five drops of brandy 
should be administered every hour to two hours in the breast-milk. 

In the simple inflammation the navel should be bathed with lukewarm 
water three or four times daily, and the ointment of the oxide of zinc be 
constantly applied ; or if there is little or no discharge, the navel may be 
dusted with the powdered oxide of zinc. In case of ulceration the navel 
should be gently washed three or four times daily with lukewarm water, 
to w r hich carbolic acid is added — three or four drops to the ounce ; and if 
there is much inflammation, a light poultice of pulverized slippery elm 



UMBILICAL HEMORRHAGE. 71 

should be applied in the interval, or if the inflammation is moderate, the 
balsam of Peru. If gangrene supervene, the parts should be frequently 
bathed with the carbolic-acid-water, and a cloth soaked with it be applied 
over it. The slough should be detached as soon as it is so far separated 
that its removal causes no hemorrhage, after which the treatment for 
ulceration is appropriate. 

Umbilical Granulations or Fungus. 

TThen the cord falls, granulations sometimes sprout out from the ex- 
posed raw surface, and complete cicatrization is impossible till they are re- 
moved. They form a rounded mass of a pale reddish hue, at the centre of 
the umbilical fossa, bleeding when rubbed, and causing constant moisture 
of the umbilicus. The largest which I have seen had perhaps twice the 
side of a large pea, and they may be of any smaller size. 

Treatment — By pressing upon the umbilical parietes the tumor rises 
from the fossa, so that a silk ligature can be applied around its base, when 
the mass can be readily removed with the scissors. If the granulations 
are small, they may be removed by the scissors, without the ligature, and 
hemorrhage prevented by touching the surface with lunar caustic. 



CHAPTER XII. 

UMBILICAL HEMORRHAGE. 

The granulations which have been described above sometimes cause 
considerable hemorrhage when injured. The profuse and even fatal hem- 
orrhage which occurs at birth, or soon after, from too loose a ligature of 
the umbilical cord, or from laceration or other injury, is so well known, 
and its cause so apparent, that it need only be alluded to in this connec- 
tion. Bouchut details a case in which death occurred even before birth, 
from this form of hemorrhage. The child was- attached to the placenta 
by a very short cord, which prevented delivery till it parted by the trac- 
tion of the forceps ; but the bleeding from the umbilical vessels was so 
profuse, that the child was pallid and lifeless when born. 

There is another form of umbilical hemorrhage, cases of which have 
been from time to time observed for more than a century (one of the first 
on record was reported in the Gentleman's Jlagazine, April, 1752, by Mr. 
Watts, a physician in Kent, England), but little was done to elucidate its 
nature till three American physicians made it the subject of careful study, 
and the monographs which they have published upon it are the best which 



72 UMBILICAL HEMORRHAGE. 

the literature of the profession affords. Dr. Francis Minot read his paper, 
containing the statistics of 46 cases, before the Boston Society for Medical 
Improvement, in April, 1852. Prof. Stephen Smith prepared his paper, 
containing the statistics of 79 cases, for the New York Statistical Society, 
in 1855. It was published in the New York Journal of Medicine for that 
year. Dr. J. Foster Jenkins presented his monograph as a report to the 
United States Medical Association in 1858, and it was published in the 
Transactions of the Association for that year. This paper is very valuable 
on account of its statistics, as the writer succeeded in collecting the records 
of 178 cases, from medical journals, and gentlemen of the Association. 
These three papers contain nearly all that is known in reference to this 
disease. 

Sex — Age Females are less liable than males to this hemorrhage. 

In Jenkins's cases, 34^- per cent, were females, 65J males. The following 
table gives the age at which the hemorrhage commenced in 99 cases : — 

Age. Nos. 

Under 1 day ......... 5 

Under 2 days .7 

Under 3 " 6 

Under 4 " .7 .3 

5 to 7 " (inclusive) .32 

8 " 10 " " 25 

11 " 15 " " 16 

16 " 21 " " .4 

56 " 1 

99 

Ordinarily the hemorrhage commenced very soon after detachment of 
the cord, but in not a few the cord was still adherent. 

Causes The common proximate cause is feeble coagulability of the 

blood. In the normal state, when the cord is ligated, the fibrin of the 
blood, which now ceases to flow in the umbilical vessels, forms coagula so 
firm that, by the time the cord is detached, hemorrhage is impossible. 
But in the majority of those affected with this disease, the clots are so soft 
and loose that they do not present any effectual barrier to the pressure of 
blood, which therefore oozes through them or presses them away. This 
lack of coagulability is easily demonstrated, for if a little blood, as it 
escapes, is caught in a vessel, it will be found to remain liquid a long 
time. This dyscrasia, or morbid state of the blood, which we therefore 
recognize as a chief cause of the hemorrhage, does not have the same 
origin in all cases. It is sometimes due to inherited syphilis. The infant 
affected with it may be plump, and appear well at birth, but in most in- 
stances, when the hemorrhage is to occur, it is puny and cachectic, ex- 
hibiting also local manifestations of the disease with which it is affected. 
Thus, in a case in my practice, the infant, puny, and apparently born 



UMBILICAL HEMORRHAGE. 73 

before term, was observed to have several blebs of pemphigus on the first 
day, from some of which blood soon began to ooze, but the fatal umbilical 
hemorrhage did not commence till after two weeks. 

In about one-fifth of the cases ecchymoses or petechias have been ob- 
served upon various parts of the surface, affording additional proof of the 
general blood disease. 

Jaundice is another cause of impoverishment of the blood in the new- 
born, and therefore of umbilical hemorrhage. The writers who have col- 
lected records of the hemorrhage, all remark the frequent occurrence of 
the icteric hue, both before and during the bleeding. It is not improbable 
that, in certain instances, the jaundice is hematogenous, arising from de- 
struction of the red corpuscles and liberation of the haematin, a not 
unusual result of a profound dyscrasia, whether syphilitic or originating 
in some other cause. But in other, and probably most instances, the jaun- 
dice proceeds from the liver, and is the cause of the change in the blood. 
Thus, in five of Jenkins's cases, there was occlusion of the hepatic or 
common bile-ducts, and jaundice, from the presence of biliary acids in the 
blood, causes diminution in the amount of fibrin and red corpuscles. In 
the ordinary form of icterus neonatorum, the cause of which is found in 
the relative fulness of the capillaries and minute bile-ducts in the acini of 
the liver, the coagulability of the blood must evidently be impaired in pro- 
portion to the degree and duration of the jaundice. 

Poor health of the mother, and impoverishment of her blood during 
gestation, whether from chronic disease, as tuberculosis, or anti-hygienic 
conditions, also cause impoverishment and diminished coagulability of the 
blood of the child, and are therefore causes of the hemorrhage. The ex- 
cessive use of diluent drinks or alkalies by the mother is believed by some 
to have a similar effect. 

In certain cases the hemorrhage is due to an inherited hemorrhagic 
diathesis. In nine of Jenkins's cases the mothers were subject to menor- 
rhagia, and liable to bleed freely after parturition, and from injuries ; and 
seventeen other mothers had each lost more than one infant from umbilical 
hemorrhage. Probably in those cases in which the hemorrhage com- 
mences before detachment of the cord, and external to its point of inser- 
tion, the hemorrhagic diathesis is the main cause of the flow. 

Although the cause of umbilical hemorrhage in the majority of cases is 
the vitiated state of the blood itself, observers, among others the late Sir 
James Y. Simpson, have met cases in which the hemorrhage was referable 
to the state of the vessels. In order that the vessels be effectually closed 
by the fibrinous coagula, their walls should have their normal contractility, 
but this is in great part lost, by inflammation (arteritis or phlebitis) which 
sometimes occurs in these vessels, as we have already seen. Inflamma- 
tion, whether of artery or vein, causes thickening and infiltration of its 
parietes, loss of tone on the part of the fibres of which they are composed, 



74 UMBILICAL HEMORRHAGE. 

and therefore a patulous state of the vessel. Moreover, the inflammation 
is apt to be suppurative, and the presence of pus in the vessel obviously 
hinders the formation of a firm and effective coagulum. 

Symptoms.— Ordinarily umbilical hemorrhage occurs without any pre- 
monition, but sometimes it is preceded by jaundice. Jenkins ascertained 
that jaundice was a prodromic symptom in 41 out of 178 cases, and besides 
the icteric hue, constipation, clay-colored stools, deeply tinged urine, etc., 
were sometimes recorded. Rarely colicky pains and vomiting preceded 
the hemorrhage. The blood may be arterial or venous, or both. It oozes 
slowly or rapidly, rarely escaping in a jet, even when there is reason to 
believe that it is arterial. 

Prognosis This is unfavorable. Statistics show that five in every 

six perish. The prognosis is. most unfavorable when jaundice or purpura 
is present. Those are most likely to recover who have a healthy parent- 
age, no obvious dyscrasia, and in whom the hemorrhage occurs late, and 
is not profuse. The average duration of the hemorrhage in 82 fatal cases 
in Jenkins's collection was three and a half days, the minimum being only 
three hours. After the arrest of the hemorrhage, death may occur from 
exhaustion or the dyscrasia. 

Treatment The treatment should be both constitutional and local. 

It is important, so far as time will permit, to treat the dyscrasia, and as 
the stools are apt to be constipated, a laxative is ordinarily indicated. A 
laxative is not only useful for its effect on the hepatic circulation, but as 
a derivative. Both Smith and Jenkins recommend calomel for this pur- 
pose. The modes of treating the bleeding parts have been various. Those 
most deserving of mention are the following : Injecting a styptic into the 
open vessels, applying a styptic by compress or sponge to the navel, cover- 
ing the navel with dry or wet plaster of Paris, constant pressure with the 
finger, which is tedious, but which maternal solicitude willingly provides, 
and lastly, the use of needles with ligature. All of these methods have 
been more or less successful in arresting the hemorrhage, but the last is 
most effectual, though painful. Two needles should be passed through the 
umbilicus at right angles, and a waxed thread wound around each in the 
form of the figure 8. In four or five days the needles should be removed, 
and a poultice or simple dressing applied. 



FEATURES, ETC., IN DISEASE. 75 



CHAPTER XIII. 

DIAGNOSIS OF INFANTILE DISEASES. 

General Observations. 

Diseases in early life differ in important particulars from those occur- 
ring in maturity. Some which are common in the former age are un- 
known or are rare in the latter, and those which occur equally at all ages 
often present peculiar symptoms and a peculiar clinical history in the 
young. Therefore physicians who are skilful in treating adults, may be 
unskilful in treating children. Excellence as a physician of children can 
only be achieved by special and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there is a 
great amount of sickness and a large mortality, diagnosis must evidently 
be made from the objective symptoms ; from examining the features, atti- 
tude, utterances, the pulse, respiration, etc., and inspecting the surfaces, 
so far as they are accessible to view, and the eliminated products. We 
lack for this age the important information which speech affords. Some 
general remarks, therefore, in reference to the appearances and functions 
of the system in early life, and the changes which they undergo in various 
pathological states, seem requisite, in order to a clearer appreciation of the 
symptoms, and more ready diagnosis of individual diseases. 

Features, External Appearance of Head, Trunk, and Limbs in Disease. 

In the new-born, as soon as respiration and the new circulation are es- 
tablished, the cutaneous capillaries become distended with blood, and the 
skin presents a congested appearance. By the close of the first week this 
external hyperemia begins to abate, and is soon replaced by the normal 
capillary circulation. 

Icterus is common in the first and second week. Bouchut attributes it 
to mild hepatitis. A much more plausible view of its causation, and pro- 
bably the correct one, is that of Frerichs, who attributes it to the effect on 
the hepatic circulation of ligation of the umbilical cord. By ligation the 
current of blood through the umbilical vein to the liver ceases, the amount 
of blood in the hepatic capillaries, which connect with the branches of the 
vein, diminishes, and then, according to Frerichs, diversion occurs of a 
part of the bile from the hepatic cells into the capillaries, while the rest 
flows in the normal manner in the bile-ducts. The degree of jaundice is 



76 DIAGNOSIS OF INFANTILE DISEASES. 

proportionate to the amount of bile which enters the circulation. Icterus 
neonatorum is not a disease of importance. It subsides without medicine 
in the course of one or two weeks, when the circulation through the liver 
becomes equalized and regular. 

The surface, or portions of the surface, of the new-born often present 
for a few hours a livid color, due to the mode of delivery. Protracted 
lividity occurs from atelectasis or malformation in the heart or great ves- 
sels ; lividity induced by exertion or excitement, while the respiration is 
normal, indicates malformation of the heart or vessels ; temporary lividity 
sometimes occurs in severe acute diseases, especially those of the respi- 
ratory organs; lividity, whether temporary or permanent, is a sign of 
imperfect decarbonization of the blood. 

The cheeks of children are congested in febrile and inflammatory dis- 
eases, except in a cachectic or prostrated state of the system. Transient 
circumscribed congestion of the face, ears, or forehead constitutes a reliable 
sign of cerebral disease. Strabismus occurring in connection with febrile 
reaction, oscillation of iris, inequality of pupils, and drooping of upper eye- 
lids, also denote cerebral disease. The pupils are contracted during sleep ; 
evenly dilated in death. 

Dilatation of the ake nasi during inspiration, with contraction of the 
eyebrows and a countenance indicative of suffering, attends severe inflam- 
mation of the respiratory organs. Absence of tears during the act of 
crying shows a severe and probably fatal form of disease in infants over 
the age of four months. 

Rapid wasting of the features, causing deep suborbital depressions, 
prominence and pointedness of the cheek-bones and chin, and hollowness 
of the cheeks, is a sign of a severe diarrhceal affection ; the most striking 
examples of this sudden collapse of features are afforded by patients 
affected with cholera infantum. In severe cases of this disease the physi- 
ognomy, from a state of fulness and health, presents in a few hours such 
a wasted and senile appearance that the friends with difficulty recognize 
the features with which they are familiar. Muscular tonicity is also greatly 
impaired in this disease, that of the orbicular muscles of the lips and eye- 
lids to such an extent that the mouth is open and eyeballs exposed during 
sleep. Great emaciation occurring gradually, is a symptom of subacute 
or chronic disease of a grave character, often of tuberculosis or chronic 
entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. 
It is then due to simple paralysis of one or more of the motor muscles of 
the eye. But when supervening upon other symptoms of a neuropathic 
character, it is a grave symptom, indicating organic disease of the enceph- 
alon, as effusion, meningitis, etc. A permanently downward direction of 
the axes of the eyes, with smallness of the face and great expansion of the 
cranium, is a sign of congenital hydrocephalus. The scalp in this disease 



ATTITUDE — MOVEMENTS — THE VOICE. 77 

is tense, bald, or sparingly covered with hair, the fontanelles and sutures 
open and enlarged, and the cranial bones yield to pressure. Great expan- 
sion of the cranium above the ears, while the frontal portion is not en- 
larged, or but slightly, denotes hypertrophy of the brain. 

The appearance of the general cutaneous surface possesses much greater 
diagnostic value in the diseases of infancy and childhood than in those of 
adult life. The eruptive fevers so common in the young, and compara- 
tively rare in the adult, reveal themselves to us in great part by the changes 
which they cause in the appearance of the integument. The peculiar color 
of the skin in constitutional syphilis, hereafter to be described, and which 
is more marked in infancy and early childhood than at any other age, is 
a diagnostic sign of great value in obscure cases. In the infant the cold 
stage of intermittent fever is manifested, not by muscular tremors, but by 
lividity, pallor, and the goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails are signs 
of cyanosis, and therefore of malformation at the centre of the circulatory 
apparatus, or of tuberculosis, or chronic pulmonary disease attended by 
malnutrition. Enlargement of the spongy portions of bones, causing pro- 
minences, softness, and bending of the bones, and consequent deformity 
of the limbs, patency of the fontanelles, a large and square shape of the 
head from calcareous deposit external to the cranium, are among the signs 
of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or which 
connect by their orifices with these surfaces, are slightly developed. There- 
fore sensible perspiration and lachrymation are rare under the age of three 
months. A thick Meibomian secretion of a puriform appearance collect- 
ing between the eyelids, is an unfavorable prognostic sign ; it indicates a 
state of great depression ; it is observed most frequently in cerebral and 
intestinal affections a little before death. Passive congestion of the vessels 
of the conjunctiva sometimes occurs under the same circumstances, due to 
feebleness of the heart's action, and imperfect capillary circulation. It 
indicates the near approach of death. 

Attitude — Movements — The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs with 
a degree of rigidity, adduction of the great toe, clonic or tonic spasm of 
the muscles, irregular movements of one or more limbs, with consciousness 
impaired, or with mental hallucinations, are symptoms of grave disease 
of the cerebro-spinal system. Irregular muscular movements partly con- 
trolled by the will, and occurring during full consciousness, are symptoms 
of chorea, a disease nearly always ending favorably in children, though 
incurable in the adult. Contraction of the eyebrows, turning of the eyes 
and face from light, avoidance of noises, as if painful, are signs of head- 



78 DIAGNOSIS OF INFANTILE DISEASES. 

ache. Frequent carrying of the hand to the ear, and pressing with the 
ear against the breast of the mother or nurse, are symptoms of otalgia. 
Frequent carrying of the lingers to fhe mouth, in connection with fretful- 
ness or other symptoms of suffering, indicates stomatitis, gingivitis whether 
from difficult dentition or other causes, painful pharyngitis, or some ob- 
structive disease of the larynx. Frequent rubbing or pressing the nose 
may be due to intestinal worms or intestinal irritation from other causes. 
It may be due to coryza or headache. Frequent forcible rubbing or strik- 
ing the nose should lead to a careful examination and perhaps guarded 
prognosis. It often indicates grave cerebral disease, and may be a pre- 
cursor of convulsions. 

In severe obstructive disease of the larynx, the child is restless, moving 
from side to side. In most inflammations of the respiratory organs, a semi- 
erect position gives most relief. The voice in severe laryngitis is often 
hoarse or indistinct, and usually so in the pseudo-membranous form; in 
pleuritis or pneumonitis it is restrained and abrupt, since the movements 
of the walls of the chest give pain. 

The voice in severe diseases of the abdominal organs is feeble and plain- 
tive. It is sometimes short and restrained in acute dyspepsia, in perito- 
nitis, and in cases of great abdominal distension. The horizontal position 
gives most relief in abdominal diseases. In case of abdominal pain the 
patient often presses his hand upon the abdomen and flexes his thigh over 
it. Perfect quietude, with features sunken, and unchanged by smile or 
crying, is a symptom of severe and exhausting diarrhoeal affections. 

Respiratory System. 

The respiration of the infant under the age of six months is very irregu- 
lar, and it is more irregular the nearer the time to birth. If the new-born 
infant is closely observed, it will be seen to sigh often; it breathes pretty 
uniformly and regularly for a moment, and then, without appreciable 
cause, the respiration is intermitted; it holds its breath when it smiles or 
moves its head, or even its limbs ; it is very subject to hiccup ; this is 
more common the first week of life than at any other age. So much is 
the breathing of the young infant disturbed by these causes, that the num- 
ber of respirations ordinarily varies in consecutive minutes. In order, 
therefore, to determine with accuracy the frequency of the normal respira- 
tion for this time of life, it is necessary to take the average of several 
observations. 

At birth, while the function of the heart has for months been regularly 
performed, the lungs are still quiescent. The one organ has been active 
during the greater part of foetal development, the other is yet untried. 
Hereafter, in the new order of things, so intimate is the relation between 
the heart and lungs, that the proper performance of the function of the one 



RESPIRATORY SYSTEM 



79 



is essential to that of the other. Therefore the commencement of respira- 
tion and the return of circulation, which is modified and temporarily ar- 
rested at birth, are nearly simultaneous. Respiration commences in the 
first half-minute of independent existence; often, indeed, attempts to in- 
spire occur before the delivery is completed. The exceptions to this early 
establishment of respiration are, after tedious or unnatural births. The 
return of circulation is a moment later. 

Respiration in Health As the air-cells at birth are closed, the 

establishment of respiration is difficult. The air at first penetrates a few 
pulmonary cells, but gradually more and more are inflated through the 
forcible inspirations which the crying of the infant produces, till after a 
variable time respiration becomes easy and complete. If the cry is feeble, 
and especially if with this feebleness there is considerable congestion of the 
brain, the result of tedious birth, the full establishment of respiration is in 
a corresponding degree gradual and slow. 

The frequency of the respiration in health should be ascertained, in 
order to determine whether, in a given case, it is abnormally accelerated. 
The following table embodies the result of observations, which I have 
made, in order to determine the normal frequency of respiration in the 
first year of life. 



Normal Infantile Respirati 


on (number per minute). 








Age. 






From first 


From close From close 


Close of 


Close of 






half hour to 


of first week of first 


third to close 


sixth month 






close of first 


to close of 


month to 


of sixth 


to close of 




First 
half 


week. 


first month. 


close of third 


mouth. 


first year. 






ft 


6 


ft 


s 


ft 


6 


ft 


© 


ft 




hour. 


* 


e 


* 


a> 


* 


a: 


£ 


<o 


a 








< 


< 


< 


< 


< 


< 


< 


< 


< 


< 


Number of observations 


21 


28 


14 


13 


13 


16 


10 


25 


7 


19 


6 


Extreme number of res- 
























pirations per minute. . 


25-104 


32-61 40-64 


40-96 


2S-60 32-6S 


2S-52 


36-88 


24-40 


28-64 


24-36 


Mean number of respi- 








1 












rations per minute. . . . 


4S.5 


52 52 


59 


45 51 


39 


54 


33 


41 


29 



As the child advances from the age of one year, the number of respira- 
tions per minute gradually diminishes ; but through the whole period of 
childhood it remains greater than in the adult. At the age of five years, 
when the child is quiet, but awake, it is about 27 ; at the age of ten years, 
about 22. 

Respiration in Disease. — In cerebral diseases the respiration is apt 
to be slow, and if somnolence occur, intermittent, and accompanied by 



80 DIAGNOSIS OF INFANTILE DISEASES. 

sighing. In young infants, in the drowsiness which supervenes when the 
blood is imperfectly decarbonized, during severe attacks of capillary bron- 
chitis, or broncho-pneumonia, respiration is apt to be intermittent. 

In inflammatory diseases of the larynx and trachea, respiration is but 
slightly accelerated, and, if there is no obstruction, its rhythm is normal ; 
if there is obstructive disease, its rhythm is altered ; the inspiratory act is 
lengthened. In bronchitis, respiration is accelerated in proportion to the 
degree of extension downward of the inflammation. It is in no disease 
more accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis, the respiration is accelerated in proportion 
to the extent and acuteness of the inflammation. Inspiration ending ab- 
ruptly, and succeeded by an expiratory moan, is a symptom of both pleu- 
ritis and pneumonitis in their acute stages. In certain cases of irritative 
or inflammatory disease of the abdominal organs, respiration presents a 
similar character; it is modified in this manner in consequence of the pain 
experienced in movements of the diaphragm. Ordinarily, however, in 
abdominal diseases, respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and sonorous 
in spasmodic croup, hoarse or harsh in true croup, clear and distinct in 
bronchitis, suppressed and painful in the early stages of pneumonitis and 
pleuritis, convulsive and with more inspirations than expirations in per- 
tussis. A cough due to coexisting bronchitis is one of the first and most 
constant symptoms of measles. Typhoid and remittent fevers, difficult 
dentition, intestinal worms, irritating ingesta, and severe burns, sometimes 
give rise to a cough, which is nearly dry and painless. Occurring in such 
diseases, it is sometimes dependent on more or less bronchitis, to which 
primary disease has given rise. 

Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom both in diagnosis and prognosis. It aids the practitioner in de- 
termining, approximately, not only the character but the gravity of dis- 
eases. It is somewhat remarkable, from the importance which is attached 
to the pulse in medical practice, that its natural frequency and its charac- 
ter in infancy are not more accurately known. It is true that eminent 
observers, as Trousseau and Yalleix, have published statistics relating to 
the infantile pulse in health, but these statistics disagree, and therefore do 
not afford a reliable standard with which to compare the pulse in disease. 
Moreover, some published statistics of the pulse possess but little value, 
from the small number of observations ; some from the fact that records of 
the infantile pulse are grouped with those of older children ; and others 
because the state of the infant, as regards its activity or emotions, is not 
mentioned. 



CIRCULATORY SYSTEM 



81 



Pulse in Health It is not easy to collect statistics of the healthy 

pulse for the period of infancy, which are entirely free from error, since 
there are often slight derangements of the system in the infant, which are 
not manifested by any marked symptoms, but which produce acceleration 
of the pulse. In collecting the following statistics, it was my endeavor to 
avoid sources of error so far as possible. 

In ordinary cases the movements of the heart begin about one-eighth of 
a minute after birth. They are at first slow, the ventricular contractions 
not numbering more than eight or ten by the close of the first quarter 
minute. In the second quarter the cries are vigorous, and the pulse now 
is rapidly accelerated, rising commonly above 120, and sometimes above 
160 beats per minute. In fifty-seven observations of the pulse in healthy 
infants during the first half hour of life, after the first quarter of a minute, 
I found that the extremes, with one exception, were 104 and 164 — aver- 
age, 139. ' 

Table of Infantile Pulse in Health. 





Age. 




First week. 


From close of 
first week to 
close of first 


From close of 
first month to 
close of third. 


From close of 
third month to 
close of sixth. 


From close of 

sixth month to 

close of first 








month. 






year. 




Awake. 
Quiet ; 




Awake. 
Quiet; 




Awake. 
Quiet ; 


< 


Awake. 
Quiet ; 




Awake. 
Quiet ; 


A, 

<o 

o 

32 
< 




moving 
slightly; 
nursing. 


< 


moving 
slightly; 
nursing. 


O 
a; 

< 


moving 
slightly; 
nursing. 


moving 
slightly; 
nursing. 


-e 


moving 
slightly; 
nursing. 


No of ob- 
servations 


22 


16 


10 


10 


15 


17 


25 


6 


20 


3 


Extremes.. 


104-152 


108-140 


124-160 


104-141 


112-14S 


104-132 


112-146 


104-116 


112-144 




Mean 


126 


122 

1 


139 


118 


132 


118 


129 


10S 


127 


109 



" M. Ledeberder," says Bouchut, " could only count the pulse in the 
first minute of life in six children, and he has observed from 72 to 94 
pulsations." Yalleix estimates the pulse, between the ages of two and 
twenty-one days, at 87. Trousseau states that the pulse, in the first week 
of life, varies from 78 to 150 ; and Dr. Gorham's observations are some- 
what similar to Trousseau's. My observations, as seen from the above 
table, do not correspond with the assertions of Ledeberder and Yalleix. 
Indeed, if there were no conflicting testimony, there would still be a 
strong presumption that these authors are in error, for we would not sup- 
pose that the pulse of the infant, in whom there is greater functional ac- 
tivity, both muscular and visceral, would fall so much below that of the 
foetus. It is probable, from the expression " could only count the pulse 
... in six children," that Ledeberder and perhaps Valleix counted the 
6 



82 



DIAGNOSIS OF INFANTILE DISEASES, 



pulse at the wrist, which, with exceptional cases, is very difficult and often 
impossible in the first week of life, and that they missed some of the beats, 
or, not unlikely, sometimes counted their own pulse. Immediately after 
birth there is so little force of the ventricular systole, and the extreme 
arteries,, therefore, of the system pulsate so freely, that neither in the limbs 
nor at the anterior fontanelle can the frequency of the pulse be readily 
ascertained. It can be readily and accurately ascertained only by auscul- 
tation, or by placing the hand on the precordial region, or directly after 
birth by the pulsations in the umbilical cord. 

The average pulse of the healthy infant in the first and second months 
is, according to Trousseau, 137 per minute, 128 from the third to the sixth 
month, and 120 from the sixth to the twelfth month. It is seen that his 
observations agree closely with mine, as regards infants who are quiet but 
awake. One point of interest, established by the above statistics, is the 
great diminution in the frequency of the pulse in sleep. 

Pulse during or after Active Movements or Great Mental Excitement. 







Close of first 


Close of first 


Close of third 


Close of sixth 




First week. 


week to close of 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


month. 


of first year. 




140 


162 


176 


132 


132 




160 


156 


152 


148 


144 




140 


140 


358 


148 


152 




152 


152 


144 


144 


182 




.... 


.... 


152 


156 


198 










180 


156 


160 


Extremes . 


140-160 


146-162 


144-180 


132-156 


132-198 


Mean . . 


148 


152 


160 


147 


156 



It is seen, by the above table, that by active exercise or great mental 
excitement the pulse may become as rapid as in grave diseases. There is 
greater acceleration of pulse from the emotions and from exercise in 
feeble than in robust children. Obviously, in order to determine to what 
extent the pulse is accelerated in disease, it is necessary that it should be 
counted during a state of quietude. As the age increases, it is less and 
less influenced by the emotions and physical exertion ; still, during the 
whole period of childhood, such influences do have more or less effect on 
its frequency. 

Pulse in Disease Febrile and inflammatory diseases produce greater 

acceleration of pulse in early life than in maturity. Diseases, or derange- 
ments of system, particularly those of the digestive organs, which do not 
materially affect the pulse in the adult, often cause acceleration of it in 
children. The febrile pulse of early life usually has exacerbations in its 



ANIMAL HEAT. 83 

frequency. These commonly occur in the latter part of the day. Distinct 
and more or less regular febrile exacerbations and remissions are common 
in several diseases of early life, some of which are serious, while others 
involve little danger. Among these diseases may be mentioned difficult 
dentition, intestinal worms, incipient meningitis, and constipation. An 
intermittent and irregular pulse is common in fully developed meningitis 
and certain other severe organic diseases of the encephalon. It may be 
due also to disease of the heart, and it also occurs in some children from 
temporary disturbance of the digestive function. The pulse is slow in 
compression of the brain, and also in sclerema of the new-born. 

Animal Heat. 

The internal temperature of the body in a state of health is uniform. 
In 33 infants under the age of seven days, M. Roger found the average 
temperature 98.6° Fahr., while in 25 from four months to fourteen years 
old it was 99°. The external temperature alone varies in a state of health, 
according to the temperature of the atmosphere. 

Elevation of temperature above the normal standard is a sign of inflam- 
matory and febrile affections. The increase of heat varies according to 
the character of the disease and its type. In favorable cases of inflammation 
and in simple fevers it is not ordinarily more than two or three degrees. 
The greater the severity and malignancy of inflammatory and febrile dis- 
eases, the greater the elevation. An elevation of more than six degrees 
indicates a form of disease which is likely to prove fatal. It is rare that 
the temperature, even in fatal cases, rises above 107°. In measles the 
temperature in the eruptive stage is from 101° to 103° ; in scarlatina from 
102° to 104°, if no complication exist. In diphtheria the temperature 
is elevated at first, but it is apt to fall to nearly the normal during the 
stage of profound toxasmia. 

Reduction of the internal temperature is an unfavorable prognostic sign ; 
it is observed, a few hours before death, in infants who are greatly reduced 
by certain chronic diseases, as entero-colitis. In these cases the tongue 
and even sometimes the breath communicate to the finger or hand a sen- 
sation of coldness. 

The importance of thermometric observations, as an aid to the diagnosis 
of children's diseases, is within a few years more fully recognized by the 
profession. Two diseases which, in their commencement, present very 
similar symptoms, often vary as regards the temperature. Thus, menin- 
gitis presenting in its first stages symptoms very similar to those of typhoid 
fever, has a lower temperature till an advanced period, when the amount 
of heat increases. 



84 DIAGNOSIS OF INFANTILE DISEASES. 

Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of the most 
frequent local diseases of infancy, as the various forms of stomatitis, and 
others which, though not frequent, involve great danger, as gangrene of. 
the mouth, diphtheria, and retro-pharyngeal abscess. Inspection of the 
tongue aids in determining in many cases whether the disease is pursuing 
a favorable course, or has become asthenic, and is exhausting the vital 
powers. 

Febrile movements, even when slight, give rise to coating of the tongue, 
and intumescence and distinctness of its follicles. The eruptive fevers 
are attended by changes upon the buccal and faucial surfaces which pos- 
sess diagnostic and prognostic value. Hypersemia of these surfaces appears 
early in rubeola and scarlatina, prior to those phenomena which are justly 
regarded as pathognomonic. It is therefore often an important sign in 
the initial period of these diseases when the diagnosis is obscure. The 
appearance of the fauces in diphtheria and croup, indicating not only 
the nature of the disease, but its gravity, need only be referred to in this 
connection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which are 
seated in other parts. In the infant protracted stomatitis is a common 
accompaniment of chronic diarrhoea, and it indicates its inflammatory 
nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is one 
of the first symptoms of scarlet fever, and is not uncommon, though less 
frequent, in the commencement of the other essential fevers and of acute 
inflammations. It is a symptom of indigestion, entero-colitis, cholera 
infantum, and intussusception ; it is common, also, after the paroxysmal 
cough of pertussis, and not infrequent in the bronchial inflammations of 
young infants ; in both which diseases it is excited by the muco-purulent 
matter upon the faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous membrane, 
as the experiments of Hunter and others have shown, and is in part the 
product of chemical changes in the food. A certain amount of gas in the 
intestines is normal ; it subserves a useful purpose. An abnormal amount 
of it is common in various diseases, as indigestion, chronic entero-colitis, 
peritonitis, typhoid fever. It is a frequent cause of gastralgia and enter- 
algia in the infant. In scrofulous or feeble infants, with impaired muscular 
tonicity and faulty digestion, the abdomen is often habitually more or less 
distended with gas, which does not, under such circumstances, give rise to 
pain or other local symptoms ; it has significance as showing the general 
condition of the child. 



DIGESTIVE SYSTEM. 



85 



Fig. 4. 




In the rachitic, whose thorax is compressed and liver often enlarged, 
while the vertebral column is shortened, the abdomen is commonly pro- 
tuberant. In feeble children, not decidedly 
rachitic, whose lungs are seldom fully in- 
flated, and whose chests are consequently 
depressed, the abdomen is also prominent. 
The accompanying wood-cut represents one 
of these cases, presented for treatment at the 
outdoor department at Bellevue. 

In feeble children who have suffered from 
repeated and protracted attacks of bronchitis, 
and whose chest-walls are consequently de- 
pressed, a similar abdominal prominence 
occurs. 

Retraction of the abdominal walls is com- 
mon in meningitis, and in many exhausting 
diseases. Tenesmus is a symptom of in- 
tussusception in the infant, and of colitis in 
children. 

Much light is thrown on the character of 
intestinal diseases by the appearance of the 
stools. Muco-sanguineous stools accompanied 

by fever, are a sign of colitis. Stools containing unmixed blood, and not 
accompanied by fever, may result from a rectal polypus and from purpura 
hemorrhagica. Scanty evacuations of blood, with obstinate constipation, 
are a symptom of intussusception in infants. 

The alvine discharges of infants often present a green color ; some- 
times they have the normal yellow hue when passed from the bowels, 
but become green on exposure to the air, or from reaction of the urine. 
By the microscope the green coloring matter is seen to occur in small 
irregular masses. This green substance has been supposed to be bile. I 
am convinced that as it occurs in the stools of the infant, it is commonly 
produced by the action of the intestinal secretions on the contents of the 
intestines ; perhaps the action is upon the bile, which is mingled with the 
contents, for I have often noticed that the contents in and above the 
jejunum were yellow, while in and below the ileum their color was green. 

The green hue may occur from very different causes. It may be due to 
over-feeding, to the action of cold, to irritating ingesta, to inflammation, 
etc. ; it may be transient, subsiding within a day or two, or it may continue 
several days. All infants, at times, have green evacuations, even when 
they appear in good health. 

In a large proportion of the cases of diarrhceal maladies occurring dur- 
ing infancy the stools give an acid reaction with litmus-paper. This acid, 
if in considerable quantity, is irritating, increasing the peristaltic move- 



86 DIAGNOSIS OF INFANTILE DISEASES. 

ments of the intestines, and the functional activity of the intestinal folli- 
cles, causing erythema of the skin around the anus, and reacting upon and 
intensifying the intestinal disease. Hence the indication for the use of 
antacids in the diarrhoeal affections of infancy. 

The presence of intestinal worms and the species may be ascertained 
by microscopic examination of the stools of the child who is affected with 
these entozoa. The stools contain ova, which differ in size and shape 
according to the species of worm. 

Nervous System. 

Pain. — This symptom affords important aid to the physician in deter- 
mining the seat and nature of the diseases of children. Pain in the head 
may occur in them from coryza involving the frontal sinuses, or from 
febrile movement in the commencement of an essential fever, or of inflam- 
mation of one of the organs of the trunk. Produced by such a cause, it 
abates in two or three days. If it is protracted, whether constant or 
intermittent, it is in many cases not neuralgic, as it so often is in the 
adult, but is due to organic disease of the brain or meninges. Complaint, 
therefore, of headache in a child, without any apparent general cause, or 
local cause external to the cranium, should awaken solicitude, and, if it 
is protracted, the physician should examine carefully in reference to the 
presence of a cerebral or meningeal disease. Mild frontal headache, con- 
tinuing for Aveeks or months, sometimes occurs in children suffering from 
so-called spinal irritation. In these cases pressure over the first cervical 
vertebra and the occiput is apt to increase the pain. 

Grave thoracic or abdominal inflammations in the adult are almost 
always attended by a corresponding amount of pain and tenderness ; but 
in children these symptoms are often absent, or, when present, are often 
not commensurate with the amount of disease. Thus, enterocolitis of 
nursing infants is, in a large proportion of instances, almost free from 
these symptoms, and the same may be said of many cases of pneumonitis 
in young children, namely, those cases produced by extension of inflam- 
mation from the bronchial tubes and from hypostasis. 

Pain in the chest or abdomen, occasional or constant, continuing for 
weeks or months, with fever and unattended by thoracic or abdominal dis- 
ease, indicates caries of the vertebras. Its most common seat is the epi- 
gastric, umbilical, or hypochondriac region. It is a neuralgia due to 
irritation of the sensitive root of one or more of the spinal nerves. It is a 
very important symptom to the diagnostician, showing the nature of the 
disease, which in its incipiency is so obscure. Pain in the leg, especially 
the inside of the knee, is of a similar character, indicating disease of the 
hip-joint. 

Children with certain acute febrile and inflammatory diseases some- 



THERAPEUTICS. 87 

times have hyperesthesia of portions of the surface ; it is especially marked 
upon the anterior aspect of the trunk. The physician might be misled 
into the belief that the tenderness occurred over the seat of the disease and 
indicated an inflammation ; but the pain of hyperesthesia can be diagnos- 
ticated from that of inflammation by the fact that it is so extensive, is less 
on firm than light pressure, and is especially observed upon the inner sur- 
face of the thighs. The symptoms pertaining to the nervous system occur- 
ring in the various diseases treated of in this book will be fully described 
in connection with those diseases, and, therefore, need not detain us in this 
connection. 



CHAPTER XIV. 

THERAPEUTICS. 

The young practitioner is often perplexed in deciding exactly what dose 
to prescribe, for a child, of the stronger and more dangerous medicinal 
agents. A practical rule, which holds good for many medicines, has been 
proposed by Dr. Cowling as follows : " The proportional dose for any 
age under adult life is represented by the number of the following birth- 
day divided by twenty -four." This rule is inadmissible for infants under 
the age of six months, but will apply for those that are older, for the use 
of a large number of medicines. Another rule proposed by another Brit- 
ish physician, Prof. Clarke, is based on differences in weight of children 
and adults : The adult dose is represented by 150. The dose of a child 
is determined by dividing its weight in lbs. by 150. But it is an interest- 
ing fact, and one of practical importance, that children bear and often 
require, in order to obtain the desired effect, a much larger proportionate 
dose of certain agents than adults. This is partly attributable to the 
active elimination in childhood. Belladonna is notably one of the agents 
which childhood tolerates ; and it may be added that some children can 
take a much larger dose of it than others, without producing the physiolo- 
gical effects. Thus, recently, I increased gradually a reliable preparation 
of the tincture to twelve drops for a child of four years, without producing 
the usual efflorescence ; and Farquharson says " the dose .... I have 
pushed in a child of ten, suffering from incontinence of urine, to f 3ij 
(British Pharmacop.) with good effect, and the development of mild forms 
of physiological disturbance." Arsenic is also better tolerated by children 
than adults. An infant of six months can take two-drop doses of Fowler's 
solution three times daily without ill effect. Prussic acid, strychnia, iron, 
ipecacuanha, and alcohol are also required in larger proportionate doses 



88 THERAPEUTICS. 

in childhood than is indicated by the rule either of Dr. Cowling or Prof. 
Clarke. 

When practicable, medicines should be given in the liquid form. Those 
not soluble may often be given in suspension, in some vehicle which in 
great part disguises the taste. The best vehicle for the bitter vegetables, 
as the salts of quinia, with which I am acquainted, is the elixir adjuvans of 
Caswell and Hazard. The following is the formula for its preparation : — 

R. Cort. aurant., 5 i j - 

Pulv. semin. coriandr., 

Pulv. semin. carui, aa ^j. 

Pulv. cort. pruni Virginianse, ^iv. 

Pulv. rad. glycyrrhizge, ^vj. Misce. 
Menstruum, Alcohol., partis j. 

Aquse, part. ijss. Misce. 
Percolat. 0. v, et adde — 

Syr. simplic, 

Aquse, aa Oijss. 

The elixir adjuvans may also be advantageously employed in the admin- 
istration of many other medicines apart from those which are repulsive 
on account of their bitterness. It holds them in suspension so that if they 
have a greater specific gravity than the elixir it is necessary to shake the 
bottle thoroughly before using it. The elix. taraxaci comp. is another good 
vehicle for bitter vegetables, although, like the elixir adjuvans, not offici- 
nal. I am sure from many observations, that unpleasant doses are apt to be 
wasted to a greater or less extent, and the repugnance of children to medi- 
cines employed has induced many a parent to seek other and less disa- 
greeable modes of treatment. Chemistry has greatly aided the therapeu- 
tics of childhood, in that it has enabled us, in so many instances, to pre- 
scribe the active principles in place of the large nauseous doses formerly 
employed. 



PAET II. 

CONSTITUTIONAL DISEASES. 



Fig. 5. 



SECTION I. 
DIATHETIC DISEASES. 

CHAPTER I. 

RACHITIS. 

Rachitis, or rickets, is a disease of the general nutritive process ; but 
the structural changes which attend and characterize it are most con- 
spicuous in the bones. 

Age. — Rachitis commences in most instances between the ages of six 
months and two years. Now and then we meet cases of its earlier as well 
as later commencement, and skeletons are preserved in 
museums, which seem to show that in rare instances 
rachitis is congenital. Virchow alludes to such a spe- 
cimen in the TVurzburg Museum, and Ritter von Rit- 
tershain describes another in the Museum of the Franz 
Joseph Hospital in Prague. In the Wood Museum of 
Bellevue Hospital is a similar skeleton presented by 
myself, and represented in the accompanying wood-cut. 
The infant in this case died a few hours after birth, of 
atelectasis, apparently produced by the contracted state 
of the thoracic walls. The parents are hard-working 
English people, whose surroundings are such as are 
known to predispose to rachitis. Whether this con- 
genital deformity is really rachitic, is, however, doubt- 
ful. (See Prof. Depaul, Archiv. de Tocol., Aug. 1878, 
Monthly Abstract, Phila., Oct. 1878.) 

Enlargement of the costo-chondral articulations, 
known as the " rachitic rosary," which is one of the 
earliest and most reliable signs of rachitis, has been 
observed, though rarely, in infants of two or three 
months. It should not, however, be regarded as a sign of rachitis unless 
the enlargement is so great that it can be readily appreciated by examina- 





90 RACHITIS. 

tion through the integument or by sight, for in young children, with the 
bones in the process of normal development, these joints always have a 
greater diameter than that of the ribs. After the age of two years the 
number of those affected with rachitis gradually becomes less as we pass 
towards manhood. 

Published statistics relating to the commencement of rachitis have been 
derived chiefly from European hospitals. Of 521 cases observed by Ritter 
von Rittershain, 266 were under the age of twelve months, and 91 under 
six months. Of Hillier's cases, 7 were six months old or under, 27 from 
six to twelve months, 40 from twelve to twenty-four months, 40 from two 
years to four years, and 3 over the age of four years. As rachitis so often 
commences insidiously, these statistics must be considered only approxi- 
mately correct, especially as regards those cases which are supposed to 
have had an unusually late commencement. 

Is rachitis ever developed in the adult ? Osteo-malacia, or mollities 
ossium, a rare disease of adults, occurring with few exceptions in women 
after childbirth, resembles rachitis, since it is attended with softening of 
the bones from the absorption of their calcareous element. Trousseau, 
and following him, Bouchut, believe in their essential identity, regarding 
their diiferences as due to the difference in age, and especially to the fact 
that in osteo-malacia the bone has attained its growth, whereas in rachitis 
it is still growing. Moreover, as arguments in favor of their close relation- 
ship, rachitis and osteo-malacia are found to require very similar treat- 
ment, and women after childbirth resemble children as regards aptitude 
for disease. 

Causes Rachitis, as we have stated elsewhere, is entirely distinct in its 

nature from scrofula. The scrofulous are not likely to become rachitic, 
nor the rachitic scrofulous. Proneness to low grades of inflammation or to 
hyperplasia of the lymphatic glands, which characterizes scrofula, seldom 
exists in connection with swelling of the bones or other manifestations of 
rachitis. The differences between the scrofulous and rachitic diatheses, 
which indeed seem to exclude each other, are marked. The scrofulous are 
well developed and of good height, as a rule, while the rachitic are stunted. 
Scrofula manifests itself not less frequently in childhood than in infancy, 
whereas rachitis we have seen is especially a disease of infancy. Again, 
as showing the difference between the two, scrofula is not infrequently asso- 
ciated with tuberculosis, whereas rachitis with tuberculosis is rare. 

Residence in a cold and moist climate, or in dark, damp, and ill-venti- 
lated apartments, is a cause of rachitis. Therefore it is more common in 
the north of Europe than in the warm and equable climate of southern 
Europe ; in the damp and dark basements and alleys of the city, than in 
dry and airy country residences. In deep valleys, shut out from the solar 
rays, rachitis is more common than among people of the same habits and 
social position living in elevated and sunlit localities. 



RACHITIS. 91 

A common cause of rachitis is the use of insufficient or improper food. 
This has been ascertained not only from the history of rachitic children, 
but from experiments on animals. Diminution in the relative amount of 
lime and consequent softening of the bones have been produced in various 
animals by the use of scanty food, or food deficient in nutritive properties. 
Artificial feeding of young animals at the time when nature designed that 
they should be nourished by the mother's milk has had the same result. 
(Experiments by M. Jules Guerin and others.) Rachitis is more apt to 
occur in those who are prematurely weaned than in those who nurse the 
full time. Those are most likely to become rachitic in a marked degree, 
even fatally, who at the same time have scanty and improper food, and 
reside in damp, dark, and insalubrious localities. 

An hereditary predisposition to rachitis must also be admitted, since 
infants born of rachitic parents are more likely to become rachitic than 
are those of healthy parentage. The mothers presented traces of rachitis 
in 27 out of 71 cases observed by Ritter von Rittershain. A mother in 
habitual ill health and poorly nourished, though without actual disease 
during the period of gestation, is more apt to have rachitic offspring than 
is a mother whose health is habitually good. 

It is not true, as some have stated, that all that is required to produce 
rachitis is a certain lowering of the vital powers, since all greatly enfeebled 
infants would become rachitic, whereas only a portion of such present the 
anatomical changes which characterize this affection. Cachexia is, how- 
ever, an important predisposing cause, and therefore the rachitic state not 
infrequently supervenes on certain exhausting diseases, as the eruptive 
fevers, pertussis, and enterocolitis. There are supposed to be two direct 
causes or factors in the production of rachitis : one a deficiency of phos- 
phates in the blood, due to the use of improper food or to faulty digestion ; 
the other an excess of acids, probably mainly the lactic produced by the 
same causes, which acid or acids dissolve the phosphates in the blood, so 
that they are eliminated from the kidneys, instead of being deposited as 
alkaline lime-salts in the bones. 

Anatomical Characters. First Stage. — M. Lebert says : " In 
rachitis the bone is diseased in all its histological elements, and the 
skeleton in its totality." It commences with proliferation of the peri- 
osteum and of the cartilages of the epiphyses. In the normal state the 
new tissue formed by this proliferation changes into bone by the deposits 
of the lime-salts, that formed from the periosteum increasing the thickness 
of the bone ; that from the cartilages, their length ; but in rachitis, as 
already stated, the osseous change does not occur. Soon the areolae, 
which abound in the ends of the long bones, in the short bones, and in the 
diploe of the flat bones, are observed to enlarge, and the laminae of which 
the compact bone is composed, to separate more or less from each other, 
forming interlamellar spaces. 



92 RACHITIS. 

The areolar and interlamellar spaces are filled with a gelatiniform fluid 
of a pale reddish color. The same substance fills the medullary canals, 
and, in certain situations, more or less of it is deposited between the peri- 
osteum and the external surface of the bone. The amount of subperiosteal 
deposit in a given place, depends in a measure on the tensity and degree 
of adherence of the periosteum. Thus when curvatures occur, the quan- 
tity of this substance deposited over the concave surface of the bone, where 
the periosteum is lax, is considerable, while over the convex surface, where 
it is tightly drawn, it is absent or scanty. This substance adheres quite 
firmly to the surface of bone, with which it is in contact, though at autop- 
sies more or less of it can be washed away by a stream of water. 

The periosteum and medullary membrane are more vascular than in 
their normal state, presenting a deep red color, and the vascularity of the 
bone itself is increased. 

Second Stage — The second stage is that of curvatures and deformity. 
The laminae of compact portions, and the walls of the areolae, in parts that 
are cancellous, become gradually thinner and more yielding. Here and 
there loss of the animal matter in connection with the mineral, occurs, pro- 
ducing new apertures and channels, in some of which bloodvessels of a new 
growth are developed. Occasionally portions of bone become detached, 
and lie as sequestra in the midst of the gelatiniform substance. The shape 
of the medullary cavity changes. The extremities of the cavity are con- 
siderably larger than its central portion. In this second stage, in typical 
cases, the relative proportion of calcareous matter being greatly reduced, 
and the new gelatiniform substance still semi-liquid, if an opportunity occur 
of examining the skeleton, the long bones can be bent, and their epiphyses, 
as well as the flat and short bones, compressed, and, in some instances, 
even crushed between the thumb and fingers. " The bones in this state can 
be cut with a knife with as much ease," says Trousseau, " as a carrot or 
other soft root." In cases in which the absorption has been considerable, 
if the bone removed from the cadaver is dried, it will be found possible to 
respire through it, so great is its porosity, and its weight is from six to 
eight times less than that of normal bone. 

If rachitis commence at an age, as it commonly does, when the diaphyses 
and epiphyses of the long bones are united by cartilage, this cartilage, not 
being transformed into bone, increases in extent and undergoes molecular 
changes, which have been minutely described by M. Broca. According 
to him, as we examine the cartilage beginning at the epiphysis, we find 
first a layer of cartilage which is but little changed, containing cells in 
their normal state. ^Nearer the diaphysis we find cartilage perforated with 
small holes, the cartilage-cells, instead of being distinct, being arranged in 
longitudinal groups, in other words, lying in longitudinal cavities, and 
flattened by mutual pressure. Near the diaphysis bands of fibrous tissue 
surround the clusters of cells. 



RACHITIS. 93 

While the anatomical changes, described above, are occurring, the liga- 
ments which unite the bones become gradually lengthened and relaxed, so 
that there is increased mobility of the bones upon each other. 

The deformities which occur in the second stage vary in degree in dif- 
ferent cases, according to the amount of rachitic softening and tumefaction 
of the bones, and relaxation of the ligaments on the one hand, and the 
movements of the patient on the other. If the patient is old enough to 
walk, the curvatures ordinarily occur first in the lower extremities ; but if 
too young to walk, they are sometimes first observed in the upper extremi- 
ties. 

Craniotabes — Occasionally the cranial bones in rachitis become very 
much thinned and softened in places, to which the name of craniotabes 
has been applied. This thinning occurs most frequently in the occipital 
bone, and sometimes to such an extent that the dura mater and pericranium 
are nearly in contact. The soft spots are yielding when pressed upon, 
and in the cadaver they are seen to be translucent when held to the light. 
Craniotabes has been invested with considerable pathological importance, 
chiefly through the writings of Dr. Elsasser. If the occipital bone is thin 
and yielding, the brain is liable to be unduly pressed upon at these yield- 
ing points, even by the weight of the head on the pillow. In connection 
with this, the clinical fact is significant that children with rachitis, and 
the softening of the calvarium which results from rachitis, are especially 
liable to internal convulsions. 

The changes in the shape of the head in rachitis are characteristic, and 
are so manifest as at once to attract attention. The growth of the cranium 
is not retarded like that of other parts of the system, and in some patients 
its volume is greater than the normal size. If there is considerable cranial 
development, hypertrophy or hydrocephalus commonly coexists. The ra- 
chitic skull does not always present the same shape. It may be elongated, 
but more frequently it approximates to a square shape. It is more or less 
flattened superiorly, laterally, anteriorly, and posteriorly. The sutures, 
which are late in closing, are commonly depressed, while the frontal pro- 
tuberances are unusually elevated. Elevation of the sutures in ridges has 
been observed in exceptional cases, as also flattening limited to one plane 
of the head, or greater in one than in the others, so as to destroy the sym- 
metry of the cranium. 

The accompanying wood-cut is of a child with rachitis, now in the 
New York Infant Asylum. It is 18 months old, has six teeth, a square 
head, softened and thin cranial bones, and a greatly depressed longitudinal 
suture. Within the last two months it has had attacks of internal convul- 
sions, in which it holds its breath and fixes its eyes, but which pass off in 
probably a quarter of a minute, without any noise. This child is very 
fretful, and dreads to be approached. In the same institution is another 
child, aged 15 months, without teeth, with a less marked rachitic head, 



94 



RACHITIS, 



and without the convulsions, but with the rachitic rosary, and a decided 
enlargement of certain of the joints of the extremities. 

The deformities of the trunk and limbs occurring in the second stage 
are interesting. There is lateral depression of the thoracic walls between 
the second or third and ninth ribs, accompanied by projection of the 
sternum. The shape of the chest resembles that of the prow of a ship, to 
which Glisson likened it, or the breast of a bird. This deformity is the 
result of atmospheric pressure, occurring externally upon the thoracic 
walls during inspiration, at the time when the ribs are most softened, and 
least elastic. Depression of the first and second ribs is partially prevented 



Fig. 6. 




by the support which they receive from the clavicles. The length of the 
clavicles is, however, somewhat diminished, and their curvatures increased, 
so that the shoulders approach each other. Below the ninth ribs the 
thoracic walls are expanded; the corresponding ribs on the two sides are 
more separated from each other than in their normal state. The expan- 
sion of the base of the chest diminishes the convexity of the diaphragm, 
and causes depression of the liver and spleen. 

The abdomen in rachitis is protuberant, partly on account of the de- 
pression of the liver and spleen, partly on account of the spinal curvatures 
and shortening of the trunk, but chiefly on account of the fact that in this 
disease the intestines are distended with gas. The meteorism gives rise 
to tympanitic resonance on percussion, except occasionally over the lower 
purt of the abdominal cavity, where there may be dulness from serous 

effusion. 

Spinal curvatures, to which allusion has been made, are common in 
rachitis. They are due to softening of the intervertebral cartilages, and 



RACHITIS. 



95 



the bodies of the vertebrae, and to laxity of the intervertebral ligaments. 
Their direction is commonly antero-posterior. They are distinguished 
from the deformity of caries by the absence of an angular projection. 
Moreover, except in cases of long continuance, the curvature can be re- 
moved by placing the patient in a horizontal position, and pressing with 
the fingers on the projecting parts. The pelvic bones also undergo change 
of shape. There is expansion of the upper part of the pelvic cavity, from 
the pressure of the abdominal viscera, corresponding with the expansion 
of the lower part of the thorax, though not in a great degree, while the 
lower part of the pelvic cavity is contracted. 

The bend of the humerus is such in most patients that its concavity 
looks inwards and forwards, but occasionally it is directly the opposite, 



Fig. 7. 



Fig. 





The concavity upon the forearm corresponds with the palmar surface of 
the hand. The concavity of the thigh presents towards the median line 
and a little posteriorly, the natural bend of the femur being simply in- 
creased. The curvatures of the tibia and fibula vary in different cases. 
If the infant has not walked, their concavity is sometimes directed for- 
wards and inwards ; but if it has walked, outward and backwards. Occa- 
sionally, the direction of the bend on one side differs from that on the 
other. 

Third Stage The third stage is that of reconstruction. After a varia- 
ble period, depending on the severity of the disease and the state of the 
constitution, the gelatiniform substance becomes more consistent, and 
points of calcareous matter appear here and there within it, The deposit 
of lime-salts continues, and the newly formed bone again becomes firm 
and unyielding. It is generally cancellous in places where the original 
bone was of this character, though the extent of the new cancellous struc- 



96 RACHITIS. 

ture is apt to be different from that in the normal bone. Thus not only 
are the epiphyses cancellous in the new as in the original bone, but I have 
seen the entire medullary cavity filled with cancellous structure. The 
subperiostal deposit is sometimes also transformed into cancelli. This was 
the character of the change occurring under the pericranium in one speci- 
men which I examined. Where the original bone was compact, the re- 
constructed bone is usually of the same character, as, for example, in the 
shafts of the long bones. Compact portions of the reconstructed skeleton 
have been said to lack the elements of true bone ; they are osteoid, accord- 
ing to this theory, and not osseous, resulting from petrifaction of the gela- 
tiniform substance. I have, however, found the elements of true bone in 
the skeletons of two individuals who had well-marked rachitic curvatures. 
The portions examined were removed from the concavities of the long 
bones, where there had been decided bending and thickening of the shafts 
from the large amount of rachitic deposit. In both specimens the osseous 
corpuscles (lacunce) and Haversian canals were easily demonstrated ; but 
in both there had been considerable growth of the bones since the rachitic 
period, and perhaps the portions which were examined belonged to this 
subsequent growth. Whether or not true bone is produced in the third 
stage of rachitis, that is, from the deposit of calcareous salts, which imme- 
diately succeeds the softening, certainly in the subsequent growth there is 
the formation of true bone. 

Such is a brief sketch of the changes which the skeleton undergoes in 
ordinary cases of rachitis. An extreme degree of softening may be reached 
in four or five months, or not till the lapse of a year or more. The third 
stage, or that of consolidation, lasts one or two years. W r hile in the first 
and second stages there is an arrest of ossification, and a deficiency of cal- 
careous salts in the system, there is often in the third stage, as Lebert has 
stated, an exuberance of ossification, and a superabundant deposit of the 
salts of lime, so that the reconstructed bone is firmer and stronger than 
normal bone. 

Occasionally, in reduced states of system, the third stage does not occur. 
The bones remain very soft and flexible, consisting almost entirely of ani- 
mal matter. This is what has been designated rachitic consumption of 
bones. Such cases end fatally after a variable time. 

A not unfrequent accident in the second period of rachitis is fracture in 
the shafts of the long bones. If there is almost complete removal of the 
mineral substance of a bone, so that the periosteum incloses little except 
the gelatiniform deposit, and the animal matter of the old bone, the limb 
bends readily, and no fracture occurs. If there is not so complete absorp- 
tion, the weight of the body or muscular exertion snaps rather than bends 
the weakened shaft. From the nature of the fracture, crepitation can 
rarely be produced. The callus is not generally abundant, and reunion of 
the bone is slow. Many cases of rachitic fractures are partial, portions of 



RACHITIS. 97 

the shaft deprived of the mineral element bending, while the part which 
retains this element is fractured. 

Rachitis retards the evolution of the teeth. Tf the disease commences 
as early as the fifth or sixth month, no teeth commonly appear till after the 
age of twelve months ; if certain teeth have appeared prior to the rachitic 
disease, an interval of several months elapses before the next are cut. 
Teeth which are developed during the rachitic state are frail, and deficient 
in enamel. They become black and carious early, and loosen in their 
sockets. If there is no tooth at the age of twelve months, the infant is 
probably rachitic. The fontanelles and cranial sutures remain open longer 
than in healthy infants. The former may not close till the third or fourth 
year, and the latter not till the second or third year. Patency of the an- 
terior fontanelle after the age of twenty months indicates rachitis. 

Although the prominent and most interesting lesions of rachitis occur 
in the bones, anatomical changes, resulting from the disease, occasionally 
occur in the soft parts. The lymphatic glands, liver, spleen, and some 
other organs not infrequently undergo waxy degeneration, diminishing 
greatly the chances of recovery. Whether this degeneration results from 
the diathesis directly, or is due to the bone disease, the substance which is 
produced is now admitted to be the true waxy material, though for a time 
denied, as it does not always give a clear reaction with iodine. 

Rachitis influences the future growth of the skeleton. The long bones, 
though unusually thick and firm, do not attain the normal longitudinal 
development ; therefore the child of ten years, who has had rachitis, is 
scarcely taller than one of six who has not been thus affected. In many 
patients the curvatures in the course of time gradually diminish, so that 
in youth and maturity the body is less misshapen than at the age of two or 
three years. It is rare, however, that the deformities entirely disappear. 

It is seen that the anatomical characters of rachitis resemble, in certain 
respects, those pathological processes which are admitted to be of an in- 
flammatory nature. The tenderness, hyperemia, proliferation, and conse- 
quent thickening of the periosteum, and the proliferation of the epiphyseal 
cartilages, are perhaps inflammatory, since they resemble more closely the 
lesions of inflammation than any other recognized pathological state. The 
soft substance, which is produced so abundantly in places underneath the 
periosteum and in the spaces of the bone, is perhaps in part an exudation, 
and in part the animal matter which is formed in the normal development 
of the bone. 1 

1 The immediate cause of the elimination of the lime salts from the kidneys, 
and the consequent arrest of ossification of the skeleton, demands further investi- 
gation. The theory stated above, that it is due to an acid, probably the lactic, 
which is generated in the intestines, during the process of digestion, receives sup- 
port from the fact, that so many who have become rachitic have previously suf- 
7 



98 RACHITIS. 

Symptoms. — The patient in incipient rachitis is quiet and melancholy, 
shunning caresses or attempts to amuse him, since movement of his body 
increases his suffering. He has general tenderness, due in part to the mor- 
bid state of the periosteum, and in part to hyperesthesia. The rachitic 
infant, therefore, unless very mildly affected, will evince anxiety and dread 
even at the approach of any one, through fear of being touched or moved. 
Trousseau says : " This change in the character of the infant, the fear 
which it experiences of seeing its sufferings return, which the pressure of 
another's hand causes, this habitual sadness impressed upon its features, 
differs from that which we observe at the commencement of other maladies, 
especially from that in the prodromic period of cerebral fevers. In truth, 
in an infant over whom this last and cruel affection is impending, we are 
able to excite again a momentary cheerfulness ; we are able, by exciting 
actively its spirits, to make it turn temporarily from this melancholy lan- 
guor, which constitutes its habitual state. It is not thus in the rachitic ; 
the more you desire to arouse it, the more you solicit its movements, the 
greater will be its impatience. It is indifferent to the plays which it pre- 
viously loved. This .... habitual sadness in an infant, who, with an 
appetite rather augmented than diminished, sensibly emaciates, who has 
constantly acceleration of pulse coincident with profuse perspiration, these 
symptoms, I repeat, have positive significance when the infant does not 
cough or present any of the signs which induce us to believe in the occur- 
rence of tubercular phthisis." 

Febrile movement, manifested by acceleration of pulse and increased 
heat of blood, is common, although, in most cases, there is no decided 
exaltation of the external temperature, perhaps in consequence, in part at 
least, of the free perspiration to which these patients are subject. 

A bruit de souffiet of greater or less intensity, synchronous with the 
pulse, has frequently been heard in rachitic cases, when the ear was ap- 
plied over the anterior fontanelle. Drs. Fisher and Whitney, New Eng- 
land physicians, first called attention to this murmur, believing it to be a 
sign of chronic hydrocephalus. MM. Rilliet and Barthez heard it in cases 

fered from indigestion and gastro-intestinal derangements. Moreover, Dr. Heitz- 
mann, now of New York, lias produced rachitic bone in the rabbit by introducing 
a considerable quantity of lactic acid in its food. Nevertheless, in the New York 
Infant Asylum, which during the last few years has afforded a good opportunity 
for observation, while certain of the cases evidently suffered from intestinal de- 
rangements, certain rachitic infants, who had been constantly under- observation 
before and during the rachitic period, were wet-nursed (some by their mothers), 
and gave no evidence of faulty digestion. They seemed to us to have as good and 
abundant nutriment as others who were not rachitic, and with fully digested and 
not too frequent alvine evacuations. It appeared, therefore, to us, that in them 
there was some unknown constitutional condition which favored the development 
of rachitis. 



COMPLICATIONS. 99 

of rachitis, and therefore concluded that the American observers had mis- 
taken the rachitic for the hydrocephalic head. Later observations have 
established the fact that this murmur possesses little diagnostic value. It 
is heard in healthy as well as diseased infants. Dr. Wirthgen detected it 
22 times in 52 children, all of whom, except four, were in good health. I 
have auscultated the anterior fontanelle in 29 infants, who were, with two 
exceptions, between the ages of three and thirty months. Most of them 
were well, or with trivial ailments which would not affect the cerebral 
circulation. In most infants with a patent fontanelle a murmur can be 
distinctly heard synchronous with the respiratory act, and in 15 of the 29 
cases no other bruit could be detected, while in the remainder, namely, 14, 
a bruit synchronous with the pulse was heard at the fontanelle. 

The rachitic, as stated above, are liable to perspirations, which are pro- 
fuse about the head and neck, so as to moisten the pillow on which they 
lie. The respiration is more or less accelerated except in the mildest 
cases, in consequence of the flexibility and diminished elasticity of the 
ribs, and the lateral depression of the thoracic walls, which prevent full 
inflation of the lungs. 

The urinary secretion is abundant, like the perspiration. During the 
first and second periods it contains a large amount of the calcareous salts, 
since the lime which enters the system with the ingesta, and which in the 
normal state is expended in the growth of bone, is eliminated from the 
system by the kidneys. 

The appetite in the beginning of rachitis is good, sometimes even better 
than in health ; but it gradually diminishes, as the disease increases in 
severity, till it is entirely lost. Diarrhoea alternating with constipation is 
common. With the continuance of febrile movement and loss of appetite, 
the patient soon begins to lose flesh, emaciation in the second stage being 
a prominent symptom. 

Since the rachitic patient sits or lies quietly, unable or disinclined to 
make exertion, the muscles become small and flabby from disuse. Depo- 
sition of fatty matter may occur between the primitive muscular fasciculi. 

Rachitis in the female infant is attended by one serious consequence, 
namely, narrowing of the pelvic cavity, from the thickening, change of 
shape, and imperfect development of the pelvic bones. Rachitis, there- 
fore, in the female greatly increases the danger of childbearing, and may 
render it impossible. 

Complications. — Rachitis is often attended by certain serious complica- 
tions, the most common of which are inflammatory affections of the respi- 
ratory apparatus. Bronchitis is one of the most common diseases during 
the age at which rachitis occurs, and even a mild form of it involves great 
danger if the ribs are soft and flexible or the thorax have the rachitic 
deformity. In these cases, since full inflation of the lungs is prevented, 



100 RACHITIS. 

collapse more or less complete of certain of the lobules is apt to occur, 
increasing the amount of dyspnoea, and therefore diminishing the chances 
of recovery ; hence bronchitis is very fatal in infants who are decidedly 
rachitic. 

Imperfect digestion of food, and unhealthy alvine evacuations, common 
in rachitic children, frequently cause diarrhoea, and, after a time, intestinal 
inflammation. The diarrhoea, especially if it has become inflammatory, 
is apt to be obstinate and dangerous, the patient becoming emaciated and 
feeble. 

Internal convulsions, the so-called laryngismus stridulus or spasm of the 
glottis, has been observed in so large a proportion of cases, that its occur- 
rence in rachitis must be considered something more than mere coincidence. 
Elsasser believed that he had discovered the cause of the laryngismus in 
craniotabes, but later observations have failed to establish the correctness 
ofliis views. Hypertrophy of brain, and chronic hydrocephalus, are also 
occasional complications. In cases of great deformity of the chest from 
rachitis, in which the lungs are more or less compressed, the pulmonary 
circulation is retarded and imperfect. This gives rise to congestion of the 
right cavities of the heart, with hypertrophy of this organ, and congestion 
of the hepatic veins, liver, and portal system. Congestion of the portal 
system may be regarded as a cause of the diarrhoeal attacks. 

Diagnosis Diagnosis is easy, except in incipient or slight cases. The 

lesions which pertain so largely to the skeleton are readily detected. Bead- 
ing of the costo-chondral articulations occurs early, and is apparent to the 
sight. Enlargement of the joints of the limbs, arrested dental evolution, 
the state of the anterior fontanelle, the peculiar shape of the head, the 
sternal projection, and rachitic curvatures, indicate positively the rachitic 
state. Profuse perspiration upon the head and neck, and the general ten- 
derness of the patient, as evinced by his cries when moved or disturbed, 
are also important diagnostic signs. 1 

Prognosis The prognosis is favorable, as regards life, if rachitis is 

recognized at an early period, and properly treated. The vicious nutri- 
tive process may be arrested, and the patient recover with but slight de- 
formity. If curvature of the long bones has occurred, and the head and 
thorax are misshapen, the patient under favorable hygienic conditions 
commonly recovers from rachitis, but with permanent deformities. 

If there is that degree of spinal curvature in the dorsal region, and de- 
pression of the ribs, that respiration is, habitually, more or less accelerated 

1 And yet rachitis, though not uncommon in the tenement-house families of New 
York, is frequently overlooked by physicians, who attribute the fretfulness, per- 
spiration, etc., to other causes. The backwardness of dentition is a notable sign 
of rachitis. Sir William Jenner says, if an infant reaches its ninth month without 
a tooth, it is rachitic. 



TREATMENT. 101 

and embarrassed, on account of compression of the lungs, the prognosis is 
unfavorable, since bronchial or pulmonary inflammation, occurring in this 
condition, is apt to be fatal. If there is much emaciation, and especially 
if diarrhoea is present, or of frequent occurrence, the prognosis should be 
guarded. In these cases there is probably waxy degeneration of important 
organs, which cannot be remedied. 

Treatment The correct treatment of rachitis is obvious when we 

consider its character and the nature of its causes. The indication is to 
restore healthy nutrition. This requires both hygienic and therapeutic 
measures. The apartment in which the child resides should be dry, airy, 
and plentifully supplied with light. He should be taken daily into the 
open air, in order to invigorate his system, but in such a way as not to 
increase his suffering, in consequence of his general tenderness. The diet 
should be appropriate for the age. It should be bland and easy of diges- 
tion, and, at the same time, sufficiently nutritious. Cleanliness of person 
and apartment, and clothing sufficient to protect from vicissitudes of tem- 
perature, are requisite. The rachitic patient of the city should, if practi- 
cable, be removed to a well-selected locality in the country. 

The medicines which are of undoubted efficacy in rachitis are cod-liver 
oil and lime. I prefer the following formula, which agrees with most 
children. 

E£. — 01. morrliuse, ^vj ; 

Syr. calcis lactopliospliatis, 
Aq. calcis, aa ^iij. — Misce. 

Give one to two teaspoonfuls three or four times daily. To it may be added the 
syrup of the iodide of iron; the vegetable and ferruginous tonics, as the citrate 
of iron and quinia. 

The compound syrup of the phosphates, the citrate of iron and quinia, 
wine of iron, iodide of iron, the various preparations of cinchona, columbo, 
etc., are the medicines which, with or without cod-liver oil, are best calcu- 
lated to restore healthy nutrition. When complications arise, the treat- 
ment should be modified to meet the exigencies of the case. Most of the 
diseases which occur as complications, require treatment similar to that 
which is appropriate in their idiopathic form, but all measures of a de- 
pressing nature should be avoided. 



102 SCROFULA 



CHAPTER II. 

SCROFULA. 

The term scrofula (scrofa, a pig, from the resemblance of the enlarged 
cervical glands of a scrofulous individual to a swine's neck) is applied to 
a diathesis, which is characterized by increased vulnerability of the tis- 
sues. The nutritive process of the tissues is readily disturbed even by 
trifling irritants or agencies in those who possess this diathesis, and, there- 
fore, the scrofulous are very prone to inflammations of various parts and 
to hyperplasia, more particularly of the lymphatic glands. Inflammations, 
which can properly be considered as dependent upon this diathesis, or as 
occurring under its influence, are for the most part subacute or chronic, 
and they differ from ordinary inflammations in the fact of a greater cell 
formation, great liability to cheesy degeneration of inflammatory products, 
so that return to the healthy state by absorption is slow or impossible. 
Moreover, this diathesis, while it gives rise to certain inflammations, which 
do not occur or are rare in other states of the system, and which all physi- 
cians at once recognize as scrofulous, often modifies those common inflam- 
mations to which all persons, whether scrofulous or non-scrofulous, are 
liable, as coryza and bronchitis, rendering them more protracted and less 
amenable to the ordinary treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, espe- 
cially the first years of it, is not entirely exempt, but scrofulous manifesta- 
tions after the age of twenty years are feeble and infrequent, disappearing 
entirely as the individual advances towards middle life. The diathesis is 
most active prior to the age of ten years. 

Causes Scrofula is congenital or acquired. Parents who had scrofu- 
lous symptoms in early life, or who are in a state of decided cachexia, as 
from cancer, syphilis, intermittent fever, or tuberculosis, are apt to beget 
scrofulous children. Insufficient nourishment of the mother during a con- 
siderable part of her gestation, and advanced age, and therefore feeble- 
ness, of the father, are occasional causes. Near blood relationship of the 
parents is also a recognized cause, and to this has been attributed the 
scrofula of royal families. Children whose father and mother are first 
cousins are, according to my observations, apt to be scrofulous. 

Again, those born with sound constitutions may acquire scrofula through 
anti-hygienic influences in the first years of life. Among the poor of New 
York we often observe one child in the family who presents scrofulous 



CAUSES. 103 

symptoms, while the rest of the children are well, and in many cases we 
are able to trace back the diathesis to some depressing cause or causes, 
which were sufficient to effect the peculiar change in the molecular condi- 
tion of the tissues which constitutes this disease. Obviously the causes of 
acquired scrofula are quite numerous. In the infant it is sometimes pro- 
duced by insufficiency or poor quality of the breast-milk, or the use of 
artificial food during the period when breast-milk is required. Too pro- 
tracted lactation also, especially if artificial food is almost wholly with- 
held, may cause it ; as may also, in those who have passed beyond the 
age of lactation, the continued use of a diet which is deficient in nutritive 
properties. 

Residence in damp, dark, and filthy apartments or streets may also pro- 
duce it. Hence one reason of its frequent occurrence among the city 
poor. Residence in a small, crowded, and imperfectly ventilated apart- 
ment has been known to produce it, even with personal cleanliness, and a 
diet sufficiently nutritive. 

Scrofula may also be caused, in those previously robust and of sound 
constitution, by disease of an exhausting nature. The eruptive fevers, as 
smallpox, measles, and scarlet fever, if severe, occasionally have this 
result, or they render active the diathesis, which had hitherto been latent. 
In this city, where chronic entero-colitis of infancy is common, I have 
sometimes been able to trace the diathesis to it. 

Can a child affected with scrofula communicate it to others? Does 
scrofula possess a peculiar principle, a materies morbi, which is communi- 
cable to others ? There is a strong popular belief that it is communicable 
by contact, and some good pathologists and high authorities in children's 
diseases are inclined to believe that the popular opinion has some founda- 
tion in fact. M. Bouchut, who holds that the scrofulous and tubercular 
diatheses are identical, says of scrofula that it has not been shown to be 
inoculable. " Nevertheless, if its contagiousness has not been demon- 
strated, we are not able to say that it will not be some day. The facts of 
vaccinia followed by impetigo, by scrofulous ophthalmia, and enlargement 
of the cervical glands attributed to the inoculation of scrofulous vaccine 
virus, and those of the contagion of phthisis by constant cohabitation, 
demand, at least for the present, a certain reserve." 

But scrofula differs widely in its nature from those diseases which are 
known to be communicable. It presents no analogy with them. We 
would not suppose, apart from observations, that a diathesis which con- 
sists in such a state or constitution of the tissues that they are easily 
wounded, possessed any inoculable principle, and, in my opinion, obser- 
vations go to show that no such principle exists. How often do we ob- 
serve children with scrofula, coryza, otorrhoea, or scrofulous cutaneous 
eruption, associating with others without communicating the diathesis ? 

Vaccination, however, affords the best opportunity for determining 



104 SCROFULA. 

whether scrofula is inoculable, and the very prevalent opinion of non- 
professional people, that it may be communicated and established through 
this operation, should have due weight. For it may be stated, as a rule, 
that a widespread popular belief in reference to a disease, which has ex- 
ternal manifestations, does have some basis of truth. 

The following are the facts in reference to this matter : — 

1st. It is the almost unanimous opinion of the most experienced vac- 
cinators that pure vaccine lymph taken from a vesicle prior to the eighth 
day, never communicates anything but vaccinia. When another disease, 
as syphilis, is communicated by the use of the lymph, it is through the 
blood, which has been mixed with the lymph by careless puncture of the 
vesicle. This opinion, so strongly established by observations, also com- 
mands assent from its reasonableness. 

2d. Vaccination of those who are decidedly scrofulous with virus from 
a healthy child, especially if the scab is employed, not infrequently pro- 
duces a sore which becomes covered with a thick and irregular crust, con- 
sisting in part of inspissated pus, and the sore is long in healing. In the 
scrofulous, also, impetiginous eruptions are apt to arise around the vaccine 
sore, and the axillary glands to become tumefied on the side corresponding 
with the vaccination. This gives rise to the belief on the part of friends 
that impure virus has been used, and scrofula communicated, while the 
fault is in the constitution of the child itself. The tumefaction of the 
glands, and the primary and secondary sores, gradually disappear, in 
most cases, leaving no ill effects, and with no subsequent manifestations 
of disease. 

3d. The vaccine crust from a decidedly scrofulous child, as it contains 
more or less animal matter, and is often pale, irregular, or broken, inserted 
in the arm of a healthy child, not infrequently produces an immediate 
inflammation with suppuration, so that the vaccine vesicle, if it forms, is 
soon broken, and an irregular sore and crust result, which present none 
of the appearances observed in the uncomplicated vaccine eruption. A 
simple inflammation, produced by the pus or other products contained in 
the scrofulous scab, has coexisted with and modified the specific eruption. 
The sore heals gradually, and impetiginous eruptions may occur around it, 
but no struma remains or is communicated. 

4th. Scrofulous manifestations sometimes appear for the first time after 
vaccinia, but they appear also after those analogous but severer eruptive 
fevers, namely, measles, scarlet fever, and smallpox. Those infectious 
exan thematic diseases which profoundly affect the constitution, it is ad- 
mitted, may be a co-operating, if not a main, cause of scrofula, and is there 
anything unreasonable in the supposition that vaccinia may have occasion- 
ally a similar effect, though less frequently or in a less degree, in propor- 
tion as it is milder ? From my own observations, I am of opinion that 
vaccinia, not vaccination, may occasionally awaken to activity the scrofu- 



CAUSES. 105 

lous diathesis, or, in combination with other causes, may even produce it 
in those who previously possessed good constitutions. It is a well-estab- 
lished fact, in the etiology of diseases, that causes which, in themselves, 
are entirely inadequate, or even insignificant, frequently produce disease 
in a system which other agencies have already prepared for it. Thus an 
excoriation gives rise to erysipelas, or a slight exposure to cold produces 
rheumatism. And so in those cases in which the friends have charged 
the production of scrofula upon vaccination, it has seemed to me that the 
most that could, with truthfulness, be alleged, was that the constitutional 
disease which had been produced by the operation, namely, vaccinia, was 
a subordinate, but, under the circumstances, a sufficient cause. 

The following is the most striking case of the apparent communication 

of scrofula through vaccination which I have met : D , West Fortieth 

Street, residing in a tenement-house, had no scrofulous affection, and was 
considered healthy till the age of eleven years. The remaining children 
of the family have never exhibited scrofulous symptoms. At the age of 
eleven years this boy was vaccinated from a scab, the source of which was 
not known, but by a physician whose practice was chiefly among the city 
poor. The sore produced was long in healing, and, before it had healed, 
the axillary glands, and those of the face and neck, began to be prominent 
and hard. From this time to the present, a period of six years, these 
glands have remained so large as to constitute a deformity, and certain 
other groups of glands, as those in the left infra-clavicular region and 
right groin, have undergone a similar hyperplasia. Examination of the 
blood by the microscope shows the absence of leucocythcemia. This case, 
at first view, certainly appears to be an example of the communication of 
scrofula through vaccination, and, for a time, I could interpret it in no 
other way. But, when we recollect the facts already stated, namely, the 
improbability of the communicability of a diathesis of such a nature, how 
frequently scrofula is acquired by children of the tenement-house popula- 
tion, solely through the anti-hygienic conditions in which they live, the 
large number of scrofulous children in the crowded quarters of the poor, 
many of which have external ailments so that the conditions for commu- 
nication are present in a high degree if scrofula were contagious, while 
the instances of its apparent communication are very infrequent, is it not 
probable that cases like this are to be explained in the manner indicated 
above, and that scrofula is not transmissible by vaccination ? 

The close resemblance clinically of scrofulous affections with the ulte- 
rior lesions of syphilis, has been adduced in support of the belief that 
scrofula, like syphilis, is due to some undiscovered specific principle. But 
the parallelism, it seems to me, is more apparent than real, and the differ- 
ence between the two diseases is so great as to destroy the validity of the 
argument. For while syphilitic manifestations result from the reception 
of a certain poison in the system, scrofula as certainly results from a 



106 SCROFULA. 

variety of ordinary depressing agencies, affecting the system in so many 
distinct ways that it seems to me unreasonable to suppose that they pro- 
duce a fixed specific principle, which, remaining in the system, causes the 
phenomena of scrofula. The facts then appear to justify the belief that 
scrofula does not possess any specific contagious principle, but that this 
constitutional anomaly is the direct result of the action of depressing 
agencies on the constitution of the tissues. 

The primary scrofulous ailments, by which the diathesis is manifested, 
occur^br the most part upon one of the free surfaces, namely, upon some 
part of the skin or mucous membrane. Certain standard authors attribute 
this to the fact that these parts are most exposed to the action of noxious 
agencies. The lymphatics lying in the inflamed area take up the altered 
lymph and carry it to the adjacent lymphatic glands, which become irri- 
tated, and undergo hyperplasia, and perhaps ultimately suppuration. This 
is, in a large proportion of cases, the beginning and the cause of scrofulous 
ailments. Nevertheless, in not a few instances, the first manifestations 
are in deep-seated and covered parts, as when scrofulous periostitis or 
osteitis occurs, without any peripheral lesion. 

Anatomical Characters There are no ascertained anatomical 

changes in the blood which are peculiar to scrofula. As long as the ap- 
petite and general health remain good, and the local affections have not 
occurred, the composition of this fluid is, so far as known, unaltered. In 
the cachexia, which is present when the general health is impaired, the 
blood becomes impoverished, the red corpuscles lose a portion of their 
coloring matter, and the watery element predominates. 

Does the glandular hyperplasia of scrofula produce an excess of the 
white corpuscles? Virchow says (Cellular Pathology, Lect. IX.): "Dur- 
ing the progress of an attack of scrofula, in which, if the disease run a 
somewhat unfavorable course, the glands are destroyed by ulceration, or 
cheesy thickening, calcification, etc., an increased introduction of corpuscles 
into the blood can only take place as long as the irritated gland is still, in 
some degree, capable of performing its functions, or still continues to exist; 
as soon, however, as the glands are withered or destroyed, the formation 
of lymph-cells likewise ceases, and with it the leucocytosis. In all cases, 
on the other hand, in which a more acute form of disturbance prevails, 
connected with inflammatory tumefaction of the gland, an increase of the 
colorless corpuscles always takes place in the blood." Although the glan- 
dular hyperplasia occurring in scrofula increases the number of white cor- 
puscles in the blood, scrofula cannot be regarded as sustaining any causative 
relation to that great and constant increase of white corpuscles which 
characterizes the disease leucaemia ; for this disease, as remarked by Nie- 
meyer, does not occur in childhood, when the scrofulous diathesis is active, 
but in manhood, when it has ceased to exist, or has become latent. 

Strumous inflammations of the cutaneous and mucous surfaces, which 



ANATOMICAL CHARACTERS. 107 

we have seen are the initial lesions in a large proportion of scrofulous 
cases, do not present any peculiar anatomical characters. Some of them 
are attended by an abundant formation of cells, and by dense infiltration 
of the inflamed tissues; but inflammations which do not depend on the 
strumous diathesis may present these same characters. The most marked 
differences between the strumous and non-strumous peripheral inflamma- 
tions are found in their origin, amount, of cell-formation, and duration. 

The swelling of the lymphatic glands, which is so common in the neigh- 
borhood of scrofulous ailments, and which we have seen is in most instances 
the result of "conducted irritation," is due to hyperplasia of the lymphatic 
glands, with comparatively little or no increase of the stroma. Thus hyper- 
plasia of the cervical glands is common, resulting from eczema of the scalp 
or face, or from otitis, or any of the forms of stomatitis ; and so pharyn- 
gitis often gives rise to hyperplasia of the tonsils which are lymphatic 
glands. The scrofulous nature of the glandular enlargement is apparent 
from the fact that it continues long after the primary inflammation which 
gave rise to it has abated. Lymphatic glands sometimes enlarge in those 
who are not scrofulous, either from direct injury or propagated inflamma- 
tion, but the tumefaction is commonly less in degree, and in most instances 
it soon abates when the exciting cause is removed. 

The glands which most commonly undergo scrofulous enlargement are 
the cervical, inguinal, bronchial, and mesenteric; but in those who are 
decidedly scrofulous, the glands in the vicinity of any protracted inflam- 
mation are very prone to hyperplasia. Thus I have seen enlarged and 
cheesy glands in the vicinity of scrofulous ostitis, or periostitis. 

Under favorable circumstances the glandular enlargement abates after a 
short time by absorption of the redundant cells. But the products of hy- 
perplastic or inflammatory action in the scrofulous individual are very apt 
to undergo cheesy degeneration, and the close causative relation of this 
cheesy substance with tubercles is now admitted. If resolution do not 
soon occur in the gland, it begins to undergo cheesy degeneration. It be- 
comes firm and inelastic, its nutrient vessels narrowed and compressed, 
so that circulation through it ceases, and its cells, losing their liquid and 
vitality, shrivel away. This necrobiotic process appears in points in the 
gland, which enlarge and unite, till finally the whole gland becomes a 
dead mass, with shrivelled elements, of a whitish appearance, like cheese, 
the resemblance to which has suggested the name by which the degenera- 
tion is known. 

A cheesy gland not infrequently acts as an irritant, like inorganic mat- 
ter, producing suppurative inflammation, and its history thenceforth is 
that of an abscess. Purulent matter mixed with the cheesy debris escapes 
by ulceration upon the nearest surface, and a scrofulous ulcer is the result, 
which slowly heals, leaving a permanent cicatrix ; calcification of a cheesy 
gland occurs in exceptional instances. 



108 SCROFULA. 

The cervical lymphatic glands, having undergone hyperplasia in the 
scrofulous child, not infrequently continue painless and indolent for a con- 
siderable time, producing according to their size an unsightly appearance, 
and without undergoing cheesy degeneration. Finally one or more be- 
comes inflamed, and the broken down gland substance softens and is ex- 
pelled, mixed with pus through an ulcerated opening in the skin. 

In order to complete the description of the anatomical character of 
scrofula, it would be necessary to describe the various inflammations to 
which the diathesis gives rise. Those which are most common and im- 
portant occur in the skin, mucous membrane, connective tissue, the joints, 
the bones with their periosteal covering, and the eye and ear ; eczema and 
coryza are very common scrofulous ailments. Phlyctenular keratitis with 
great intolerance of light, otitis externa, causing protracted otorrhosa, or 
media and interna, causing deep-seated pain, with impairment or loss of 
hearing, offensive purulent discharge, and in the gravest cases caries of the 
mastoid cells or caries extending along the petrous portion of the temporal 
bone even to the brain, causing meningitis and death, are not uncommon 
manifestations of scrofula, in the families of the city poor. Strumous cellu- 
litis, occurring independently of the glandular affection, and quickly ending 
in suppuration, is also common. The term cold is applied to the abscess 
when the local symptoms are slight, and there is but little heat of the 
parts. In young children the common seat of these abscesses is directly 
under the skin, so that if subcutaneous cellulitis running into an abscess 
occur in a young child, he probably has the strumous diathesis. 

The osseous system is also very prone to inflammation in the scrofulous. 
Periostitis, ostitis, aud arthritis, rare in those with healthy constitutions, 
are common in the scrofulous, in whom they result, even from very slight 
injuries, and sometimes without the recollection of any injury, and appa- 
rently from the direct influence of the diathesis. These inflammations 
are more common in the lower extremities than in the upper. Periostitis 
may occur independently of inflammation of the bone, where its usual 
seat is upon the shafts of the long bones, and it also accompanies inflam- 
mation of the bone, as pleurisy accompanies pneumonia. The osseous 
inflammations of strumous patients are of two kinds: first, the destructive, 
producing caries with suppuration, or necrosis; and, secondly, the so-called 
fungous, in which there is proliferation of tissue as in white swelling. 
Often both these processes coexist, granulations and new tissue springing 
up, while the carious or necrotic process is extending. 

Dactylitis is in most instances when occurring in young infants a syphi- 
litic affection, but in children of one year or more, in whom no marked 
syphilitic symptoms have previously occurred, it originates from the stru- 
mous cachexia, as in the following case: Charles R., aged twenty months, 
was admitted into the New York Infant Asylum in 1876. He had always 
been pallid, and had a strumous aspect. A physician acquainted with his 



SYMPTOMS. 



109 



parentage states positively that he is free from syphilitic taint, but when a 
few months old he had a mild form of coryza, which gradually abated un- 
der anti-strumous treatment. At the age of five months he had purpura 
hemorrhagica of a severe form, but apparently not accompanied by hemor- 
rhage from any of the mucous surfaces. The patches of extravasated 
blood were quite numerous, and large over the trunk and limbs, and it 
was nearly three months before they entirely disappeared. A few months 
subsequently he began to have offensive otorrhoea on one side, which did 
not entirely cease. In December, 1876, at the age of eighteen months, 
well marked dactylitis was first observed, involving the first phalanx of 

the left middle finger. The swell- „ 

° Fig. 9. 

ing was somewhat tender, and the 
skin which covered it had a slight- 
ly reddish or pinkish tinge, indi- 
cating the inflammatory nature of 
the malady. Neither joint at the 
extremity of the phalanx was in- 
volved, so that the movements 
were unimpaired. The dactylitis 
increased somewhat after it was 
first discovered, and then began 
to decline, under treatment with 
the cod-liver oil and syrup of 
iodide of iron. The accompany- 
ing wood-cut represents the out- 
lines, obtained by tracing the 
hand of the infant, when pressed 
on paper. 

Symptoms. — The scrofulous 
diathesis is exhibited by certain* 
physical signs, which are present in infancy, but are more manifest in 
childhood. In one class of strumous children, they are as follows: Form, 
tall and slender; quickness of movement and perception; intelligence, 
good ; skin, thin and semi-transparent, through which the superficial veins 
are distinctly seen ; features, delicate ; cheeks, habitually pale or florid, 
and flushed by slight excitement; eyes, bright, with bluish conjunctiva; 
muscles and bones, slender in proportion to their length. Those children 
who present these peculiarities are said to have the erethitic form of the 
diathesis. 

Others have what has been designated the torpid scrofulous habit, which 
is characterized by softness and flabbiness of the flesh, distended abdomen, 
large head, broad face, slow, languid movements, and an over-production 
of fat in the subcutaneous connective tissue in certain situations, espe- 
cially the nose and upper lip. Though typical cases can be readily re- 




110 SCROFULA. 

f erred to one or the other of these forms, there are many cases which are 
intermediate. 

One of the earliest of the scrofulous manifestations is subcutaneous 
cellulitis, alluded to above, giving rises to abscesses, commonly not large, 
with little surrounding induration, little pain, tenderness, and heat, and 
slow in discharging ; in a word, indolent. The most frequent seat of these 
abscesses is upon the extremities, but they may occur upon the scalp or 
elsewhere. They gradually heal when the pus escapes, their site being 
indicated for a considerable time by the depression and reddish discolora- 
tion of the skin, which gradually returns to its normal state. Ordinarily, 
these abscesses do no harm apart from the reduction of the general health 
which they effect, but when occurring in localities where the connective 
tissue lies upon the periosteum, as upon the fingers, periostitis may result, 
with destruction of the surface of the bone. Again, thrombi may occur 
in the veins of the inflamed part, giving rise to emboli, embolismal pneu- 
monia, and death. Specimens from such a case were presented by me to 
the New York Pathological Society in 1868. 

The scrofulous affections of the skin often also occur at an early age, 
even before dentition. They are more frequent in infancy than in child- 
hood. The most common are eczema and impetigo, and of rare occur- 
rence, ecthyma and lupus. But all of these may occur in those who are 
not strumous or who do not present the characteristics of the strumous 
diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; in other cases 
there is an exciting cause, as exposure to cold ; but the inflammation, once 
established, continues on account of the diathetic condition. It is some- 
times a matter of doubt whether a mucous inflammation is of such a char- 
acter that it is proper to designate it scrofulous, especially if it occur upon 
such surfaces as are often the seat of ordinary inflammation. If the child 
has heretofore presented symptoms of scrofula, if the inflammation is sub- 
acute, and there is no apparent cause to originate or sustain it apart from 
the diathesis, it is probably of a strumous character. The diagnosis is 
rendered more certain by observing the effect of anti-strumous remedies. 
The most frequent of these scrofulous inflammations of mucous surfaces 
are coryza, tracheo-bronchitis, and conjunctivitis. More rarely,, stomatitis, 
pharyngitis, vaginitis, and, according to some, entero-colitis, are of a stru- 
mous character. Coryza gives rise to snuffling respiration, the formation 
of crusts around and within the nares, and excoriation of the upper lip. 
The tracheo-bronchitis is attended by thickening of the mucous membrane, 
increased production of mucus and epithelial cells, and a loud tracheal 
rale, accompanying each inspiration. 



SYMPTOMS. Ill 

Strumous inflammation of the mucous 'membrane of the trachea and 
bronchial tubes is not a very infrequent disease in this city. It sometimes 
originates in a simple inflammation from cold, or the tracheo-bronchitis of 
measles, or pertussis, and it is apt to continue, with its rales, cough, and 
scanty expectoration, for months, unless relieved by a proper course of 
treatment. 

Among the most common of the strumous affections, are inflammation 
of the eyelid, designated psorophthalmia, and that of the eye itself. The 
former is characterized by redness and thickening of the lids, detachment 
of the eyelashes, and inflammation and altered secretion of the " Meibo- 
mian glands ;" the latter, namely, strumous ophthalmia, by pain, lachry- 
mation, photophobia, and a moderate degree of hyperemia of the affected 
organ. One of the most common serious results of strumous inflammation 
affecting the eye, arises from the conjunctivitis and keratitis, namely, the 
formation of phlyctenular and ulcers on the margin of the conjunctiva 
and upon the cornea, fed by newly formed vessels. If not controlled by 
proper treatment, they may result in opacities more or less permanent, or 
possibly, worse still, in perforation, with its consequent ill effects. 

Inflammations of the external and middle ear have their origin very 
generally in the strumous diathesis. Occasionally there is an exciting 
cause of the otitis, as an injury, or severe constitutional disease like scarlet 
fever. Protracted otitis, whether external or internal, and especially that 
form of it which leads to ulceration, destruction of the ossicles, and caries 
of the petrous portion of the temporal bone, it is proper, in a large pro- 
portion of cases, to regard and treat as strumous. 

I have stated that inflammations of the osseous system are common in 
strumous children. Some of the best observers and highest authorities, 
as regards the surgical diseases of children, both in this country and 
Europe, state that they do not consider these affections to be of a strumous 
nature ; while others regard them as manifestations of struma. After care- 
fully examining the reasons for this variance in opinion, I am convinced 
that the difference of views in reference to this matter occurs from a dif- 
ferent understanding of the nature of scrofula. Those who state that the 
affections alluded to are not scrofulous, believe, so far as I have been able 
to ascertain, that scrofula and the tubercular diathesis are identical. As 
tubercles are not, as a rule, present in children who suffer from these affec- 
tions, it is therefore held that these affections are not scrofulous. If those 
holding this belief were told, or could be made to believe, that scrofula is 
entirely distinct from the tubercular diathesis, that it is merely a name 
applied to a diathetic condition in which the tissues are easily wounded, 
there would probably be but one opinion as regards the scrofulous nature 
of these inflammations. For, as I have often had an opportunity to ob- 
serve, they occur in a large proportion of cases from very trivial injuries, 
showing a highly vulnerable state of the tissues. 



112 SCROFULA. 

Holmes, in his useful and eminently practical Treatise on the Surgical 
Diseases of Children, says of one of the most common of the affections 
alluded to, namely, morbus coxarius : "The affection in question occurs 
very frequently in strumous children, a circumstance which has led to its 

being denominated strumous If by strumous be meant a state of 

the system which renders the subject of it prone to the deposit of tubercle 
in the viscera, I think that there is good reason for asserting that morbus 
coxarius often attacks children who are not strumous, i. e., who display no 
such tendency to the deposit of tubercle." Still, Mr. Holmes states u that 
there is that condition of the system which disposes its subjects to the 
development of low inflammations of various kinds," which is almost the 
full definition of scrofula, as understood by us. 

The stubbornness and frequent disastrous consequences of scrofulous in- 
flammation of the skeleton are well known. Nearly every bone, as well 
as its periosteum, is liable to this form of inflammation, but some are more 
frequently affected than others. Inflammation of the bone may terminate 
by resolution, by the formation of an abscess, or, and frequently, by cari- 
ous or necrotic destruction of the bone itself. Necrosis is most apt to 
occur in the shafts of the long bones, caries in the spongy extremities of 
these bones, and in the spongy portions of the short bones. If abscesses 
form, the pus may finally escape from the system by a tedious ulcerative 
process, or, retained, may undergo cheesy degeneration. Scrofulous 
arthritis, if early detected and properly treated, may resolve, leaving no 
ill effect ; if otherwise, suppuration, ulceration, cartilaginous and osseous, 
and anchylosis, are apt to result. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are 
more liable to cheesy degeneration, and the prognosis is therefore less 
favorable. The most frequent of these inflammations, and the one of 
chief interest, is pneumonia. Catarrhal pneumonia, so frequent in early 
life, whether primary or secondary, in connection with measles, pertussis, 
etc., is a disease often involving grave consequences in those who are 
decidedly scrofulous ; since, instead of resolving, the affected lung-tissue 
presents a strong tendency to caseous degeneration, ending in consumption 
of the lungs and death. I have most frequently noticed cheesy pneumonia 
during extensive epidemics of measles, as a complication or sequel of this 
disease. It may occur in those who are not scrofulous, if the vital powers 
are greatly reduced, but it is so much more common in the scrofulous, that 
some recent writers have designated this form of inflammation by the 
term scrofulous, instead of cheesy, pneumonia. From the fact, however, 
of its sometimes occurring in the non-scrofulous, the term cheesy or case- 
ous, especially, too, as it expresses the anatomical state, seems more 
appropriate. 



RELATION OF SCROFULOSIS TO TUBERCULOSIS. 113 

Relation of Scrofulosis to Tuberculosis — Tuberculosis, in a 
large proportion of cases, results from an infecting substance, which is 
produced by caseous degeneration. In the caseous substance when it 
softens are found fat globules, albuminous granules, and a large amount of 
substance in solution. These are reabsorbed to a greater or less extent, 
and in them is the virus, which, lodged in healthy tissue, causes the pecu- 
liar cell proliferation, by which the tubercle is produced. The theory that 
the virus acts as an embolus intercepted in the capillaries, has its advo- 
cates. In certain instances the intimate causative relation of the cheesy 
substance to the tubercular neoplasm appears from the fact that tubercles 
are developed in abundance in the cheesy focus, while there are no tuber- 
cles in other parts of the system. Fungous and ulcerative inflammations 
occurring in the osseous system afford common examples. Now since 
cheesy substance occurring in the system of a young person results, in 
most instances, from the products of those inflammations which we recog- 
nize as scrofulous — for the products of inflammation occurring in those 
who are not scrofulous seldom undergo this change — we see the intimate 
relation between scrofulosis and tuberculosis, and why for a long time the 
strumous and tubercular diatheses were considered identical. 

Prognosis. — As scrofula may be acquired through anti-hygienic influ- 
ences, so it may disappear, or become latent through influences of an oppo- 
site character. Therefore the manifestations of scrofula may be limited 
to a brief period, or they may occur at intervals through the whole of 
childhood, and the first years of youth. "When the diathesis is inherited, 
and fostered by unfavorable circumstances, the scrofulous affections appear 
earliest, are most varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, but the 
danger to life depends on the nature and extent of the scrofulous inflam- 
mation. The most common unfavorable result is the occurrence of pul- 
monary or general tuberculosis from the infection supplied by the cheesy 
substance, in the manner stated above. This is the usual result from 
cheesy pneumonia. The next most common cause of death, either directly 
or indirectly, is inflammation of the osseous system. Many deaths occur 
from inflammation of the vertebrae, or of the hip or knee joints, when it 
has been allowed to continue a considerable time without proper treatment. 
Protracted suppurative inflammation of the bones is apt to produce amy- 
loid degeneration of organs, which is permanent, and likely to prove fatal, 
or death may occur from exhaustion, with or without tuberculosis. 
Among the city poor meningitis is not very uncommon, consequent on a 
long continued otitis media and caries of the petrous portion of the tem- 
poral bone. Permanent impairment of the sight and hearing often results 
from neglected strumous ophthalmia and otitis. 

After the age of puberty the strumous affections cease, and among the 
8 



114 SCROFULA. 

most robust adults are those who in early life presented indubitable 
symptoms of the strumous diathesis. 

Treatment. Prophylactic — Measures designed to prevent scrofula 
are impossible without the co-operation of willing and intelligent parents. 
It is obvious that the prevention of congenital scrofula requires the treat- 
ment of disease or impaired health in the parent. If parents should be 
taught, or should remember that good health in themselves is the neces- 
sary condition of the inheritance of a sound constitution in the child, and 
should adopt such therapeutic and regimenal measures as would procure 
this, the number of cases of inherited scrofula would be materially 
reduced. 

As the first years of life are very important, both for correcting the dia- 
thesis when inherited, and for preventing its development in those of sound 
constitution, care should be taken that the regimen of the child be such 
as would in no way produce deterioration of the general health. The 
nursing infant, if the mother is in poor health, should be provided with a 
healthy wet nurse, for in young children the diathesis may be acquired 
solely by the use of food that is scanty or of poor quality. Those old 
enough to be weaned should have plain and nutritious diet, with a proper 
admixture of animal food. More or less outdoor exercise, and residence 
in a salubrious locality with sufficient air and sunlight, are requisite. 

Curative As scrofula originates in a state of weakness existing in the 

parent in the congenital, and in the child in the acquired form of the dis- 
ease, and is characterized by feeble resistance of the tissues to irritating 
agents, the inference is reasonable that all tonics have, to a certain extent, 
an anti-scrofulous effect upon the system. The ordinary vegetable tonics, 
and sometimes the ferruginous, are indeed useful in the treatment of scro- 
fula. Employed in connection with proper regimenal measures they are 
sufficient, in many cases, to remove the diathesis after a time, or render it 
latent. Besides these medicinal agents, which tend to correct the scrofu- 
lous diathesis by their general tonic effect, there are certain others which 
experience has shown to be beneficial in the treatment of scrofulous affec- 
tions, and which are, therefore, largely used. One of these is cod-liver 
oil, which contains iodine with numerous other ingredients. 

Cod-liver oil is useless or nearly so in the torpid form of the diathesis, 
which is characterized by an increased deposit of fat in the subcutaneous 
connective tissue, slow circulation, and sluggish muscular movements. 
On the other hand, in the treatment of the erethitic form it possesses real 
value. Its protracted use in such cases does so modify the molecular con- 
dition of the tissues that they are less liable to inflammation, and the dia- 
thesis is, therefore, rendered milder or removed. From one to three tea- 
spoonfuls, according to the age, should be given three times daily. While 
we frequently experience so much difficulty in administering it to adults 
affected with tuberculosis, and sometimes find it necessary to discontinue 



TREATMENT. 115 

its use on account of its nauseating effect, scrofulous children rarely refuse 
to take it, and it does not seem to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous 
affections, but it is a question whether it has not been overrated as a 
remedy for the diathesis itself. Iodine employed internally is especially 
serviceable in glandular hyperplasia, and in scrofulous thickening and 
induration of the connective tissue and periosteum. In general, it should 
not be administered to children in its isolated state, on account of its irri- 
tating properties, but one of its compounds should be employed. The 
compounds which are chiefly prescribed in the treatment of scrofula are 
the iodides of starch, iron, potassium, and sodium. If, as is frequently the 
case, the patient is pallid, and his appetite poor, the iodide of iron should 
be preferred ; if not in this cachectic state, the iodide of starch. Pharma- 
ceutists prepare syrups of both these iodides, so that they can be readily 
administered to the youngest child. The iodide of starch may be admin- 
istered by dropping from one to five drops of the officinal tincture of iodine 
on a little powdered starch, and giving it in syrup. These iodides are 
preferable to the iodides of potassium and sodium for internal administra- 
tion to children, as they are not irritating to the mucous membrane, and 
the iodine is readily set free. Prof. Dalton has, indeed, demonstrated that 
the iodide of starch is decomposed in most of the liquids of the body, and 
the iodine liberated. 

In New York city a large proportion of the scrofulous children are 
cachectic, and need iron, and the iodide of iron is more frequently em- 
ployed, and with good results, than any other iodine compound. The 
syrup of the iodide of iron, which is readily absorbed, should be given in 
one to two-drop doses three times daily to a child of six months, and one 
additional drop added for each additional year. Among the vaunted 
remedies of scrofula are phosphoric acid and the phosphate of lime. I 
have not employed these agents without at the same time using other 
remedies, and cannot say, therefore, to what extent they have been cura- 
tive in my practice. Probably there is no better combination of remedies 
for the strumous diathesis than the following, which is now used in some 
of the institutions of New York : — 

R. 01. morrhupe, 2 parts ; 

Syr. calcis lactopliosphat., 1 part. Misce. 

Dose, one teaspoonful to a dessertspoonful three or four times daily, to 
each dose of which the syrup of the iodide of iron may be added at the 
time of its employment. 

The internal use of mercury as an antidote for scrofula is now generally 
discarded ; unless, perhaps, in those cases in which the diathesis is imme- 
diately dependent on syphilis, its use for this purpose, from what we know 
of its therapeutic effects, would probably be more injurious than beneficial. 



116 SCROFULA. 

Among the medicines which have from time to time been employed for 
the cure of scrofula, some of which have had considerable reputation but 
have nearly fallen into disuse, are walnut leaves, sarsaparilla, elecampane, 
conium, digitalis, horseradish, compounds of silver, gold, arsenic, baryta, 
and bromine. It is probable that none of these has any effect on scrofula 
or scrofulous ailments, except such as improve the appetite and general 
health, as horseradish. 

The same hygienic measures are required in the treatment of scrofula 
as are demanded in the prophylaxis of it. The nursing infant should have 
healthy breast milk, and if its mother belong to a tubercular or scrofulous 
family, or is feeble, a healthy wet nurse should be employed, or it should 
be sent to the country where suitable cow's milk can be obtained. In the 
city, the infant may be fed during the cool months with porridge made of 
the best cow's milk and barley flour, rice flour, Ridge's or Nestle's food, 
or one of the preparations of Liebig's soup ; but, as stated elsewhere, such 
food will prove disastrous to infants under the age of twelve months 
who are kept in the city during the hot term. Their removal to the coun- 
try is indispensable, both as regards the treatment of struma, and to pre- 
vent intestinal catarrh. The expressed juice of beef slightly boiled, given 
several times daily in small quantity to infants, aids materially in restoring 
a better nutrition of the tissues. Obviously similar care is necessary in 
the selection and preparation of the food of children, who have passed 
beyond the period of infancy. While the diet should be highly nutritious, 
it should be plain, and easily digested, and given at sufficient intervals so 
as not to overtax digestion. 

Fresh air, out-door exercise, daily bathing, personal and domiciliary 
cleanliness, are very necessary for the most successful treatment of the 
diathesis. Since scrofula is comparatively infrequent in farming sections, 
scrofulous families are greatly benefited by farm life, with all the acces- 
sories to health which pertain to it. 

The local scrofulous ailments require additional and special treatment. 
Those located on the cutaneous and mucous surfaces are less dangerous, as 
a rule, than the deeper seated inflammations ; still they should be promptly 
treated not only for the inconvenience and annoyance which they cause, 
but because they are apt to lead to hyperplasia of the neighboring glands, 
which sometimes proves serious. Thus a pharyngitis may cause a peri- 
pharyngeal adenitis and abscess, and a bronchitis may cause an adenitis of 
the bronchial glands, with the probability of their cheesy degeneration. 
The so-called bronchial phthisis is believed to result in a large proportion 
of cases from a strumous bronchitis, which has been allowed to run on 
uncontrolled by medicine, and a similar state of the mesenteric glands may 
result from intestinal catarrh in the strumous. Inflammations of the skin 
and mucous surface occurring in the strumous require the continued use 



TREATMENT. 117 

of anti-strumous remedies, conjoined with such treatment, designed to act 
locally, as is appropriate in individuals who are not strumous. 

It is the common practice to treat the enlarged glands of struma by daily 
applications over them of the stronger iodine preparations. This treat- 
ment does not cause absorption of the redundant gland substance. It 
causes proliferation of the epidermic cells, and quickens the cell change in 
the gland underneath so that leucocytes are apt to form in it. Cutaneous 
inflammation as eczema or impetigo causes hyperplasia of the lymphatic 
glands underneath. In like manner strong applications, which irritate the 
skin, are apt to quicken the cell formation, so that suppuration is a com- 
mon result. I once produced accidentally such an amount of vesication 
over an enlarged, hard, and apparently indolent gland in an infant of four- 
teen months, that I was very anxious lest a sore would result, which would 
heal with difficulty, and yet instead of dispersion of the glandular swelling 
the pathological processes were so promoted that suppuration and discharge 
of pus occurred by the time that the cuticle had reformed. 

We know no better substance for the local treatment of strumous ade- 
nitis than iodine, and it should be applied, in my opinion, in such a 
manner that it is absorbed with the least possible irritation of the gland. 
The following will be found useful ointments and solutions for the treat- 
ment of these cases : — 

fy. Potas. iodidi, gj, 
Ung. stramonii, ^j. 

To be rubbed over the gland several times daily. It should not be ap 
plied as a plaster, as it is too irritating and will vesicate. I have known 
a glandular swelling, which had continued about three months, to disap- 
pear in three weeks under its use in connection with internal remedies. 
Vaseline, in place of the stramonium ointment, makes a nicer preparation. 

]£. Liq. iodiuii composita, 
Glycerine, equal parts. 

To be applied as an inunction. The glycerine renders the skin soft and 
in a favorable state for absorption. 

In The Medical Press and Circular for August 3, 1870, J. Waring 
Curran states that he has used with great success what he designates a 
new iodine paint, consisting of half an ounce of iodine, the same quantity 
of iodide of ammonium, twenty ounces of rectified spirits, and four ounces 
of glycerine. 

Mercurial ointments have been recommended by writers of reputation 
for the treatment of these glands. I have employed them, and known 
them to be employed, but cannot say that I have ever observed any benefit 
from their use whatever. In the children's class at the Out-door Depart- 
ment at Bellevue we have discarded them entirely for this purpose, although 



118 SCKOFULA. 

both the citrine and white precipitate ointments, diluted with an equal 
quantity of lard, have been used with much apparent benefit for chronic 
coryza of a strumous nature, and also occasionally for external otitis of the 
same nature. 

In a paper read at the meeting of the British Medical Association in 
1870, by Mr. Jordan, the writer recommends, as attended with success, 
vesication, not over the gland, but at a little distance from it, as, for ex- 
ample, behind the neck, for treatment of the cervical glands. But a mode 
of treatment which seems so unlikely to be beneficial requires stronger 
proof of its utility than has yet been presented. 

When the gland becomes actively inflamed, as indicated by increased 
heat and tenderness, and redness of the skin, applications of iodine are no 
longer proper. They increase the local disease. There is no longer any 
probability of resolution of the glands, and poultices should be applied. 

In strumous conjunctivitis and keratitis the solution of sulphate of 
atropia, two grains to the ounce of water, should be dropped three times 
daily into the eye. It relieves the photophobia, while it exerts a curative 
effect on the inflammation. To remove the phlyctenula and opacities, 
finely powdered calomel should be dusted into the eye every second day. 
For the otitis, injections of tepid water to which a little carbolic acid is 
added (gr. ij to iij to the ounce) should be employed, and afterwards a 
mild astringent. 

It is very important that the diseases of the osseous system should re- 
ceive early and correct treatment, and it is in reference to these inflamma- 
tions that error of diagnosis is made. Thus, I have known periostitis, 
with the diffused redness of the skin and heat which it produces, to be 
mistaken for erysipelas, until the diagnosis was corrected from its persist- 
ence and non-extension. It is remarkable that strumous arthritis some- 
times appears in two or more joints at once, as in the case related below. 
I have known it to occur nearly simultaneously in three joints, though 
only for a brief time in two of the joints, while it was chronic in the other. 
Hence, the fact that this inflammation is often mistaken for inflammatory 
rheumatism, and treated as such for a few days, till its nature becomes 
apparent ; and so the febrile movement, lassitude, abdominal pain, etc., of 
vertebral caries are, in a large proportion of cases, attributed to some- 
thing else, and the true disease not suspected till irreparable damage has 
occurred, or much longer confinement and treatment required than would 
have been, with an earlier diagnosis. 

The common strumous inflammations of the osseous system which involve 
the joints, as Pott's disease, hip-disease, and white swelling, are usually 
quite amenable to treatment, early applied, which insures complete rest ; 
but, as a rule, cases neglected, or wrongly treated, go from bad to worse. 
There are exceptions, for a case may do well or terminate with moderate 



TREATMENT. 



119 



Fig. 10. 



deformity without treatment, as in the following interesting instance, 
which also shows the difficulty which often attends diagnosis : — 

Anna D., aged six years, came to the children's class in the Out-door 
Department at Bellevue in February, 1877, with the following history: 
Her health was good till two years ago, when she complained of pain of 
a mild form in both knees. Her parents attributed it to her rapid growth, 
and she was always able to walk with little suffer- 
ing. Slowly but steadily these joints began to 
swell. She has had no pain in other joints, and 
no member of the family has had rheumatism ex- 
cept a grandparent. She walks without complaint 
to the rooms of the Bureau. The affected joints 
are about equally swollen, and it is evident on 
examination that they contain some serous effu- 
sion. Direct pressure is not painful, but pressing 
the bones together with a twisting or rotating 
movement gives some pain. She is pale, and has 
a strumous aspect. A sister of fifteen years has a 
similar swelling of one knee, which began at the 
age of seven or eight years, but which has received 
no regular treatment, has not prevented the free 
use of the limb, and has given her little inconve- 
nience. 

The physicians who have examined this child, 
one of whom is an expert in orthopaedic surgery, 
agree that the disease is strumous and not rheu- 
matic ; that it did not, during two years of neglect 
and unrestrained motion, go on to suppuration, 
and destruction of the joints, was probably due to the good general health. 

Though the result in the above case was good, since there was little im- 
pairment in the use of the joints, and no suffering, yet delay and neglect 
in the treatment of all those strumous inflammations which involve the 
joints is exceedingly dangerous, for if left to themselves they more fre- 
quently end in suppurative inflammation and ulceration, with all the sad 
consequences which these entail. Strumous inflammations of the osseous 
system now receive more early and correct treatment than formerly, and 
orthopasdia, almost unknown till within the last twenty years, has become 
an important branch of surgery. Formerly in New York, especially in 
the tenement houses, we often met emaciated bed-ridden children with 
strumous osteitis and arthritis, their limbs swollen, and painful on motion, 
and offensive from the discharge, for the most part shunned by physicians, 
and with no prospect of relief except by amputation. Now this spectacle 
is comparatively infrequent. The early symptoms of these diseases being 




120 TUBERCULOSIS. 

better understood and sooner recognized, the plaster of Paris or starch 
dressing to insure immobility, or ingeniously devised steel splints, which 
produce extension, and allow motion of the limb without friction of the 
inflamed surfaces, coming into general use, a large proportion of cases do 
not go beyond the first stage and are cured. 



CHAPTER III. 

TUBERCULOSIS. 

The term tuberculosis is applied to a disease which is characterized by 
the formation of small nodules, developed in one or more organs. 

Etiology The tubercular diathesis may be inherited. Hence the 

well-known fact of tubercular families. Cases are not infrequent in which 
hereditary tuberculosis proves fatal before the death of the affected parent. 
The offspring of a tubercular parent does not, as a rule, have tubercles at 
birth ; but the tubercular diathesis, at first latent, as in syphilis, manifests 
itself in a few weeks or months in the formation of tubercles, and in the 
consequent cough and emaciation. In two cases which I recall to mind, 
a cough from tubercles was observed, according to the statement of 
friends, as early as the second or third week after birth. Under good 
hygienic conditions, the inherited diathesis may remain latent or be re- 
moved. If both parents are tubercular, the offspring almost necessarily 
become so. 

Tuberculosis frequently results from prolonged anti-hygienic conditions 
in those previously healthy and of healthy parentage. It may result from 
residence in damp, dark, and dirty apartments, from scanty or unwhole- 
some food, protracted and exhausting diseases, in fine, from any agency 
which gives rise to great and continued impoverishment of the blood. 
Age is a predisposing cause. Tuberculosis is comparatively rare under 
the age of one year, while it is not uncommon in wasted infants between 
the ages of two and five years. This remark is fully substantiated by the 
statistics of the Nursery and Child's Hospital and Infant's Hospital of 
this city. 

Is tuberculosis propagated by infection ? Most physicians would an- 
swer in the negative, though in some countries, as in Italy, it is stated 
that the profession have long regarded it as mildly infectious. Every phy- 
sician of experience must have remarked the frequency with which tuber- 
culosis occurs in those not predisposed to the disease, but who have been 
in intimate relation with consumptive patients. This has been commonly 
regarded as due in no way to infection, but has been thought to be a coin- 



ETIOLOGY. 121 

cidence, or has been attributed to an influence not fully understood, which 
the emotions or imagination exert in the causation of diseases. But re- 
cent discoveries concerning the etiology of tuberculosis, which will pre- 
sently be related, afford ground for the opinion which some of our best 
authorities in the pathology of tuberculosis, as Waldenburg, now hold, 
that minute particles exhaled or expectorated from the lungs may be the 
medium of infection. 

In December, 1865, M. Villemin read before the Academy of Medicine 
of Paris and published his celebrated memoir, which contained the results 
of his experiments in inoculating certain lower animals with tubercular 
matter. Since then the fact has been established by many experiments, 
that tubercle may be produced in the rabbit and other animals by insert- 
ing under their skin various pathological products, whether tubercular or 
non-tubercular, as gray tubercles, cheesy products, thickened pus, etc., 
and by inserting finely divided foreign substances, not animal, as anilin 
blue, and also by traumatic irritations which give rise to the formation of 
inflammatory products under the skin, as the use of a seton. The coloring 
matter, whether introduced alone or in combination with a pathological 
substance, is found in the tubercle which results in the lungs or elsewhere. 
Therefore, it is inferred that tubercle in these experimental cases is pro- 
duced by minute particles of the inserted substance, which enter the circu- 
lation and are deposited in the lungs or other organs. Where they are 
deposited, inflammation (formative irritation) occurs, with proliferation of 
the cellular elements of the part. This corpusculation produces the tubercle. 

The importance of these discoveries is apparent. Cheesy substances 
produced in the system, whether in the lungs, lymphatic glands, bones — 
as in vertebral caries — or elsewhere, and also long retained purulent col- 
lections, as in empyema, may give rise to tuberculosis, provided particles 
of the morbid substance gain admittance into the circulation. 

Blood extravasated in the alveoli of the lungs, and undergoing desene- 
rative changes, is considered a cause of tuberculosis ; but such extravasa- 
tions are rare prior to the age of puberty. Protracted inflammation of 
the air-passages, as bronchitis or laryngitis, is stated to give rise to tuber- 
cles in certain cases, but it is not easy to see how this could occur except 
when the inflammation has extended to the lungs or given rise to cheesy 
degeneration of the contiguous glands. In infancy and childhood the 
common cause is a diathesis inherited, or acquired through impoverish- 
ment of the blood by previous disease or anti-hygienic conditions, or it is 
infection of the system from cheesy glands or purulent collections. 

Post-mortem examinations in connection with these recent discoveries 
demonstrate that the immediate cause of the formatian of tubercles in the 
lungs, spleen, and other viscera, in certain cases, is hyperplasia and cheesy 
degeneration of the bronchial and mesenteric glands, whether or not this 
glandular affection is to be considered tubercular. Thus in the last two 



122 TUBERCULOSIS. 

cases which I have examined there were minute transparent tubercles in 
the lungs, some becoming yellow, evidently of very recent formation, and 
also in one of the cases in the spleen, while in both cases the bronchial 
glands were enlarged and cheesy, and in one also the mesenteric. In 
another case, occurring in the Child's Hospital, the bronchial and mesen- 
teric glands were cheesy, with all the thoracic and abdominal viscera 
healthy, while there were granulations nearly the size of a pin's head, due 
to cell proliferation, as ascertained by the microscope (tubercular), in the 
pia mater at the base of the brain, along its sides, and between the hemi- 
spheres. 

Cases are less frequent, but are occasionally observed, in which retained 
purulent collections appear to be the cause of the formation of tubercles. 
Thus, in 1870, I presented to the New York Pathological Society the lungs, 
containing minute, recent tubercles, removed from an infant, who had 
died when a few months old. The lungs were otherwise healthy, and 
there were no cheesy glands, for which a careful examination was insti- 
tuted ; but in the left thigh was a large deep-seated abscess, which had 
been detected a month before death. 

Another, and probably the most frequent local cause of tuberculosis, is 
cheesy pneumonia. Caseous degeneration of the inflammatory products 
is common in young and feeble infants affected with pulmonary inflam- 
mation, and the supposition is reasonable that particles are more readily 
detached from a caseous mass in the lungs than in most other situations. 
Certainly, in this city, cases are not infrequent of young children present- 
ing the history of pneumonia, cheesy degeneration, and finally tubercles, 
especially during epidemics of measles. 

General Anatomical Characters of Tuberculosis. — Analysis 
of the blood of tubercular patients shows an increase in the water, albu- 
men, fats, and white corpuscles, and a decrease in the number of red cor- 
puscles. The fibrin is slightly diminished, except in cases complicated by 
inflammation, in which it maybe in excess. The chief interest, however, 
as regards the anatomical characters of tuberculosis, pertains to the 
tubercle. The tubercle is as characteristic of tuberculosis as the eruption 
is of an exanthematic fever. It is produced, as already stated, by a local 
proliferation or corpusculation produced by the irritation of the tubercular 
virus in the endothelial lining of the lymphatics and bloodvessels, which 
is now regarded as the mother soil of tubercle, instead of the cells of the 
connective tissue as first taught. It is, therefore, a cell-growth, and not 
a deposit. 

If we examine with a microscope a thin section of a recent tubercle, we 
will observe in its peripheral portion, in which proliferation was active at 
the time of death, large mother cells, spindle-shaped fibro-plastic cells, and 
small round cells, which have been released from the mother cells. This 
zone of proliferation often has considerable extent. Passing towards the 



ANATOMICAL CHARACTERS. 123 

central portion of the tubercle, we find these small round cells in great 
abundance. They represent a more advanced stage of the tubercle, since 
the central part is oldest. They are the most numerous cells in the tu- 
bercle, and they have been designated the tubercle-cells. They resemble 
closely in appearance the smaller of the white corpuscles of the blood, and 
cannot be distinguished from the normal cells of the lymphatic glands, 
each consisting of a single large nucleus surrounded by protoplasm. They 
are among the most fragile of pathological cells. The cells are held to- 
gether by a transparent adhesive substance, which is firm and resisting. 

Every tubercle tends to undergo a molecular change by which its trans- 
parence is lost. This consists in a decay of the cells and the intercellular 
substance. Granules of fat are deposited within them, and the cells shrivel 
and disintegrate. Fragments of cells, and shrunken cells, and cell-nuclei 
are thus produced, which Lebert described as the tubercle-cells, and which 
were accepted as such by all observers till Virchow ascertained their true 
character. The molecular change which I have described commences in 
the interior of the tubercle, and extends outward till the whole tubercle 
becomes opaque and yellow, and at the same time so friable as to be readily 
crushed between the fingers. The yellow tubercle is therefore only an 
advanced stage of the gray semi-transparent. 

It is evident that tubercle in its first period possesses vitality, and, like 
all neoplasms, has its bloodvessels. These are soon closed by coagula or 
granular fibrin, mixed with white blood-corpusclus. When the tubercle 
has reached the yellow transformation, its vessels are no longer pervious, 
but it is surrounded by a vascular zone, in which circulation continues. 
The subsequent history of tubercle is well known. It is seldom, perhaps 
never, absorbed. It softens, and henceforth, as has been said by a Ger- 
man pathologist, its history is that of an abscess. It is an irritant, pro- 
ducing inflammation in the surrounding tissues, with thickening and 
induration, and abundant production of pus-cells, which mingle with the 
tubercle elements. Ulceration and discharge of the liquefied substance 
upon one of the free surfaces is the common result. In exceptional cases, 
instead of softening, the tubercle may undergo fibroid degeneration or 
cretification. 

Anatomical Characters^in Infancy and Childhood The ana- 
tomical characters of tuberculosis in the first years of life vary in certain 
particulars from the form which they present in the adult, but after the age 
of three years the differences are fewer and less pronounced than previously. 

Tubercular laryngitis, so common in the adult, is absent in a large pro- 
portion of cases under the age of three years, and when present has little 
intensity ; and ulceration of the larynx very seldom occurs. This has 
been attributed to the fact that there is so little expectoration in young 
children, the sputum being an irritant. Niemeyer, however, does not con- 
sider the sputum of tuberculosis sufficiently irritating to cause laryngitis 



124 TUBERCULOSIS. 

and laryngeal ulceration ; but the arguments in favor of this mode of 
causation, in my opinion, more than counterbalance those which have 
been presented against it. 

I have never met a case of tubercular ulceration of the larynx or trachea 
in the post-mortem examination of young children, nor do I recollect ever 
treating a case in which there was that degree of dysphonia which indi- 
cated ulceration. Rilliet and Barthez, in more than 300 necropsies of 
tubercular cases, found no ulcers in the larynx or trachea under the age 
of three years ; 8 cases between the ages of three and ten years, and 8 
between ten and fourteen years. The ulcers, whether seated in the larynx 
or in the trachea — and they are in most cases in the former, since the in- 
equalities upon the surface of the larynx favor the retention of the sputum 
. — are commonly small, superficial, round or elongated, and with little 
thickening or inflammation of their borders. Occurring in the folds of 
the mucous membrane, as, for example, around the vocal cords, their form 
is usually elongated. 

Bronchitis is not infrequent. This inflammation is due to, and dependent 
on, the pulmonary tubercles, and is therefore most intense in the part of 
the lung where the tubercles are most abundant and furthest advanced. 
Consequently it is more intense on one side than on the other, and it may 
be unilateral. It differs in this respect from idiopathic bronchitis, which 
is commonly pretty uniform on the two sides. It differs also in the fact 
that it is sometimes accompanied by ulcerations. The ulcers are round or 
elongated in the direction of the axis of the tubes, and, like those of the 
larynx or trachea, are superficial. Idiopathic bronchitis of infancy and 
childhood does not cause ulceration. Circumscribed inflammation may 
attack a bronchial tube, as indeed, the trachea, and give rise to ulceration 
and perforation, from the presence and pressure of a diseased lymphatic 
gland external to the tube. This subject will be treated of hereafter. 

Lungs It is well known that in the adult tubercles are always present 

in the lungs, if they occur in any part of the system. I have met two 
cases in which the lungs were free from tubercles in 36 post-mortem 
examinations of children who died of tuberculosis. One of the two was 
an infant, but its exact age is not stated in the records. It had cheesy 
degeneration of thymus and bronchial glands, enlargement of mesenteric 
glands, but without cheesy degeneration, and disseminated tubercles in 
liver and spleen. The other, fifteen months old at death, had tubercular 
meningitis, with numerous granulations upon the convexity of the brain, 
and the other usual lesions of meningeal inflammation, with bronchial and 
mesenteric glands slightly enlarged and cheesy, and one of the former 
softened. In one case, then, in 18, the lungs had escaped the disease. 
Rilliet and Barthez state that they found the lungs non-tubercular in 47 
cases in 312, and Hillier did in 25 cases in 160. In their cases, therefore, 
the lungs were exempt from tubercles in about 1 case in 7. But it is to 



LUNGS. 125 

be recollected that the statistics of these observers were prepared at the 
time when all cheesy degenerations were thought to be tubercular, and 
the bronchial and mesenteric glands are sometimes cheesy when there are 
no tubercles or lesions referable to tuberculosis in any other part of the 
system. I have records of two such cases, which I reject from my statistics 
of tuberculosis, as there is no evidence that the disease was anything else 
than cheesy inflammation. Did I include these cases, my statistics would 
more closely correspond with theirs. 

Pulmonary tubercles in children under the age of three years are, as a 
rule, discreet, and disseminated through the lungs. In cases at this age, 
which have advanced to a fatal termination, we commonly find yellow 
tubercles from the size of a pin's head to a shot in the different lobes, many 
still semi-transparent if the disease has been of short duration, but if pro- 
tracted most of them yellow, and here and there one softened and sur- 
rounded by condensed fibrous tissue. Around the semi-transparent or 
gray tubercles, many of which were growing, and therefore were in the 
state of active cell proliferation at the time of death, narrow vascular zones 
can often be detected by the naked eye. 

Under the age of three years, tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than 
the lower. 

The following are the statistics relating to the site of the tubercles in the 
lungs in the cases which I have examined. All, it is to be remembered, 
were under the age of three years : — 

Cases. 
Tubercles disseminated throughout the lungs . . .26 
Tubercles disseminated throughout the two upper lobes . 3 
Tubercles disseminated through right middle lobe and left 

lower lobe only ........ 1 

Tubercles disseminated through left upper lobe only . . 2 
Tubercles disseminated (few and semi-transparent) in left 

lung only ......... 1 

Tubercles disseminated in three points in right, and two in 

left lung 1 

No tubercles in lungs ........ 2 

36 

Between the ages of three and fifteen years, statistics show that the 
upper lobes are more liable to tubercles than the lower ; but the difference 
in liability is not great. In many cases occurring in this period, the dif- 
ferent lobes are affected nearly simultaneously, and not very infrequently 
the upper lobe is the last which is involved. In October, 1866, I made 
the post-mortem examination of a boy who died in the Children's Service 
of Charity Hospital, at the age of fifteen years, and small scattered tuber- 
cles were found in the lower lobe of the left lung, while all other portions 
of these organs were healthy. Hilliet and Barthez, who include in the 



126 



TUBERCULOSIS. 



same statistics all cases from birth to the age of fifteen years, found gray 
semi-transparent tubercles. 

Cases. 
In the right superior lobe in ...... 63 

In the right middle lobe in . . • . . .43 

In the right lower lobe in . . . . . . .55 

In the left superior lobe in . . . . . . .65 

In the left inferior lobe in . . . . . . .54 

The same observers found yellow tubercles in the 

Right superior lobe in 40 

. Right middle lobe in 28 

Right inferior lobe, in 39 

Left superior lobe in . . . . . . . .35 

Left inferior lobe in . . . . . . .31 

Tubercle, especially when softening commences, is itself an irritant, 
exciting inflammation around it. 'Inflammation occurring from this cause 
is obviously likely to be protracted, continuing for weeks or months, 
unless the tubercular matter is eliminated by ulceration. The highly vas- 
cular and delicate lungs of the young child are very liable to inflammation 
when they are the seat of tubercles, and as the tubercles are disseminated, 
the pneumonia is commonly more extensive than when it occurs from 
ordinary causes. In fifteen, or nearly one-half of my cases, there was 
pneumonia affecting portions of one or more lobes, or an entire lobe. 
From the extent and position of the solidified portions, it was obvious 
that in most instances the inflammation originated from the irritating effect 
of the tubercular matter, while in others it was due to hypostatic conges- 
tion, occurring in consequence of the long-continued recumbent position and 
the feebleness of circulation. In these fifteen cases the seat and extent of 
the inflammation were as follows : — 

Cases. 
2 



Nearly entire right lung 

Nearly entire middle and lower lobe 

Entire left upper lohe . 

A considerable part of both lungs 

Posterior parts of both lower lobes 

Posterior part of left lung . 

Left lower lobe, and right middle and lower lobes 

Left upper lobe (contained a large cavity) and posterior part 

of left lower lobe .... 
Nodules of inflamed lung around tubercles 



The inflammation in about one-third of the cases was due to hypostasis, 
as it occurred in depending portions, extended but little into the lungs, 
and sustained no relation to the amount of tubercle. It was in the stage 
of red, or more rarely of gray hepatization. 

In seven of the cases there were pulmonary cavities as large in propor- 



LUNGS. 127 

tion as we ordinarily find in tuberculosis of the adult. The seat of one 
was in the right lower lobe ; of two, the left upper lobe ; of one, the right 
upper lobe ; of another, the right lung, its exact seat not stated ; and in 
the remaining case the cavity, which was the largest of all, occupied the 
interior of all three lobes on the right side. Some idea of the size of these 
cavities may be learned by the following extracts from the records : 1st 
Case. "A small superficial cavity communicating on one side with a bron- 
chial tube, and on the other side with a small circumscribed collection of 
pus in the pleural cavity." 2d Case. " Cavity of the size of a hickory- 
nut." 3d Case. " Cavity of the size of a large hickory -nut." 4th Case. 
" Cavity three-fourths of an inch in diameter." 5th case. " A large ab- 
scess." 6th Case. " The cavity occupied nearly the whole of the interior 
of the left upper lobe." 7th Case. "About half the right lung excavated 
into a cavity which extended through the three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, 
was observed in seven cases. It was ordinarily attended by little exuda- 
tion except the fibrin, but in one case a sufficient amount of serum had 
been exuded to compress considerably the lung. Pus was not observed in 
any notable quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, 
sometimes vesicular, with fulness or bulging of the lung, an anaemic ap- 
pearance of it, and doughy, inelastic feel. In other cases emphysema was 
interstitial, producing little bladders of air under the pleura, especially 
towards the root of the lung, or separating the lobules by wedge-shaped 
or irregular interspaces filled with air. In one case air had escaped from 
an emphysematous bladder into the right pleural cavity, causing pneumo- 
thorax and collapse of the lung. 

Next to the lungs, the bronchial glands are more frequently diseased 
than any other organs, in the tuberculosis of infancy and childhood. 1 They 
undergo the successive structural changes which characterize glandular 
inflammations, namely, hyperplasia, and more or fewer of them cheesy 
degeneration and softening. In the state of hyperplasia their firmness is 
diminished, and they have a pale flesh-color. Cheesy degeneration com- 
mences in one or more points in the gland, sometimes in the peripheral, 

1 The term bronchial phthisis has long been applied to that state in which the 
bronchial glands are enlarged and cheesy. Now this glandular disease, we have 
seen, is often the result of inflammation in the strumous ; and while it may be 
the cause of tubercular infection, is probably not, in most instances, tubercular 
itself. But microscopy has not yet drawn the distinction between the cells of 
lymphatic glands, which cause the enlargement by proliferation when the glands 
are inflamed, and the cells of the tubercular neoplasm. They seem alike in the 
field of the microscope. Therefore it seems proper not to attempt to distinguish 
scrofulous glands from tubercular, when they occur in a patient affected by tuber- 
culosis. 



128 TUBERCULOSIS. 

sometimes in the central portion, and it extends till the whole gland pre- 
sents the well-known cheesy appearance. When the gland softens, the 
thick liquid presents a puriform appearance, consisting of amorphous mat- 
ter, fatty particles, and the shrivelled and disintegrated cells of the gland. 
Soon pus-cells occur, and their number increases. 

Rilliet and Barthez state that the bronchial glands were tubercular in 
249 cases in children, while the lungs were tubercular in 265 cases. All 
cheesy glands, it is to be recollected, they considered tubercular. In 4 of 
the 36 cases which I have examined, no record was preserved of the state 
of the bronchial glands ; in one case there was no perceptible hyperplasia 
and no cheesy degeneration ; in two there was hyperplasia, but no cheesy 
degeneration, while in the remaining twenty-nine cases there was cheesy 
degeneration of more or fewer of the enlarged glands, or parts of them, 
with occasional softening. In the fact that the bronchial glands are 
enlarged and caseous, we have an explanation in part of the fact, that 
the symptoms in the tuberculosis of young children differ from those in 
the adult, since Louis found the bronchial glands involved in only 
twenty-eight per cent, of the adult cases of tuberculosis which he exam- 
ined, and Lombard in only nine per cent. A gland pressing upon the 
recurrent laryngeal or pneumogastric nerve, or the trachea, may give 
rise to dyspnoea and a cough ; or on the descending vena cava or one of 
the venae innominatse, to congestion of the brain and meninges, intra- 
cranial serous effusion, and even thrombosis in the cranial sinuses. The 
fact that a softened bronchial gland not infrequently is eliminated from 
the system, by ulceration, into a bronchial tube or the trachea, is well 
known. In one case which I observed the ulceration had destroyed por- 
tions of three of the cartilaginous rings of a bronchus, and the aperture 
was plugged by a cheesy fragment of a softened gland which protruded. 
Occasionally, it is stated by authors, the ulceration is into one of the 
large vessels of the mediastinum, or even into the oesophagus. 

The following is an example of bronchial phthisis, as it commonly oc- 
curs. This case, which is not included in the foregoing statistics, was 
seen almost daily by me during its entire progress. On September 3d, 
1874, I examined an infant in the New York Infant Asylum, who had 
wheezing respiration during the last eight days. The wheezing occurred 
both on inspiration and expiration, and also, though less pronounced, dur- 
ing sleep ; pulse 96, respiration 40, temperature normal. Its mother, who 
had charge of it, and had till recently wet-nursed it, had had unequivocal 
symptoms of tuberculosis for several months. The child was pallid, and 
its flesh was soft and flabby. The fauces were perhaps a little redder than 
usual, but were otherwise normal, and a careful exploration of the chest re- 
vealed no cause of the embarrassed respiration. Auscultation and percussion 
gave a negative result. In the latter part of September a troublesome 
diarrhoea occurred, which continued more or less till near death. The 



ABDOMINAL VISCERA 



129 



Fig. 11. 





temperature on September 28th, October 8th, 10th, and 11th, was 100^°, 
100°, 99^°, and 100°. The pulse on October 10th and 11th was 1*20 and 
126. On October 8th the percussion-sound over the upper part of the 
right lung seemed somewhat duller than on the other side, though the 
respiration was not observed to be 
notably changed in the area of the 
dulness. There was but little cough 
during the entire sickness. Death 
occurred on October 20th. At the 
autopsy the bronchial glands were 
found enlarged and cheesy, and un- 
derneath the right bronchus, near the 
bifurcation, was a softened, almost 
diffluent gland, as large as a small 
hickory-nut, and compressing the 
bronchus. This, no doubt, had pro- 
duced the wheezing respiration, which 
had been the chief local symptom. 
The lungs, spleen, and in less degree 

the liver, contained numerous small miliary tubercles. Certain of the 
mesenteric glands were also cheesy, but to less extent than the bronchial. 
The disease of the bronchial glands was evidently primary, the tubercles of 
the lungs and abdominal organs being apparently quite recent. The ac- 
companying woodcut, from a photograph by Mr. Mason, the photographer 
at Bellevue Hospital, represents a posterior view of the lungs and air- 
passages. 

In no case have I found tubercles in the heart or pericardium, though 
they have been observed in rare instances in the latter. The mesenteric 
glands were enlarged by hyperplasia, and more or less cheesy, in 30 cases ; 
in their normal state, to appearance, in two cases, and in the remaining 
four cases their condition was not stated. In most of the cases the mesen- 
teric glands were smaller and less cheesy than the bronchial, but in a few 
instances they were larger than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causative relation of these 
glands to tubercles, that not infrequently the amount of hyperplasia and 
cheesy degeneration of the former was very considerable, while the tuber- 
cles in the lungs or elsewhere were small, even minute, semi-transparent, 
and evidently of recent formation. 

Abdominal Viscera In children, tubercles in the solid organs of 

the abdomen rarely give rise to appreciable symptoms, as they are small 
and disseminated, not impairing materially the function of the part in 
which they are located. On the other hand, peritoneal and intestinal 
tubercles, and the enlarged and cheesy mesenteric glands, give rise to 
symptoms which require description. The most frequent seat of perito- 
9 



130 TUBERCULOSIS. 

neal tubercles is upon the attached surface of the peritoneum, where they 
are formed from the connective tissue. They are distinctly seen through 
the peritoneum, and cause some prominence of it. Exceptionally their 
seat is upon its free surface. Every portion of the peritoneum, whether 
visceral, parietal, or omental, is liable to tubercles, but general tuberculi- 
zation of so extensive a surface does not occur in any one case. The tu- 
bercles are spherical or lenticular, and most of them small. Sometimes 
they are very numerous, but so minute as to be scarcely visible. They are 
gray or yellow, according to the age. Peritoneal tubercles often produce 
circumscribed peritonitis, causing adhesion of opposite surfaces. The tuber- 
cles in themselves cannot be detected by palpation ; but masses or plaques 
composed of tubercles and inflammatory products are sometimes so large 
that they can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal ten- 
derness or pain, meteorism, ascites — usually slight — and derangement of 
the bowels, commonly diarrhoea. As tubercles in this situation occur, in 
most cases, subsequently to tubercles elsewhere, the symptoms which have 
been described are associated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal 
tubercles is the small intestine, and more frequently its lower portion, 
near the ileo-caecal valve, than its upper or central. They are rare in the 
duodenum or contiguous part of the jejunum. They are developed ordi- 
narily in the connective tissue, either that lying under the mucous or the 
serous surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases there is 
probably no causative relation of the tubercles to the ulcers, for ulcera- 
tion of this membrane is not infrequent in the tuberculosis of children, 
when there are no tubercles in the walls of the stomach or intestines. The 
following statistics of Rilliet and Barthez, relating to this point, will aid 
in an understanding of the symptoms : — 

mi i • n -c x it- (with ulcers, 6 cases. 

Tubercles m walls of stomach, / cases, < ' 

(. without " 1 case. 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. 

m , , ,, . , .. DO ( with ulcers, 70 cases. 

Tubercles m small intestines, 82 cases, < 

(without "12 " 

Ulcers without tubercles in small intestines, 51 cases. 

Tubercles in large intestines, 15 cases, \ ' 

' (without " 5 " 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. Their 
diameters vary from a line to half an inch or more, and their general form 



SYMPTOMS. 131 

is circular, or, if two or more unite, irregular. Tubercular ulcers of the 
stomach are mostly in the great curvature, those of the small intestines in 
the ileum and lower part of the jejunum, and those of the large intestine 
in the ccecum. 

The following table exhibits the state of the principal abdominal viscera 
in the 36 cases : — 

Liver. Spleen. Kidneys. 

Tubercular 12 22 1 

Non-tubercular 16 6 21 

Not stated . 8 8 14 

Fatty . 5 

In no instance did I observe tubercular softening in the abdominal 
organs, and a large proportion of the tubercles in the liver, spleen, and 
kidneys were still in the first stage. In the five cases in which the liver 
was recorded fatty, this state of the organ was obvious to the sight, as it 
is in tuberculosis of the adult. A moderate excess of fat in the hepatic 
cells may have been present in some of the other cases, but it was not 
sufficient to be appreciable without the microscope. It is to be remarked 
that in the five cases in which the liver was recorded fatty, this organ 
contained no tubercles. The spleen is seen to have been the most frequent 
seat of tubercles of all the viscera, except the lungs. In fourteen cases 
the intestines were examined; and, in five, tubercles discovered developed 
in their connective tissue. The intestinal tubercles were small, and ulcera- 
tion had occurred of the mucous membrane which covered them. 

The brain was examined in fifteen cases. In twelve cases the amount 
of cerebro-spinal fluid varied from ^ss to £v, by estimation. In two others 
the records state that there was a considerable amount of this fluid, the 
exact quantity not being given, while in the remaining case congestion of 
the brain and meninges was noticed, but nothing was recorded in regard 
to the amount of cerebro-spinal liquid. The increase of the cerebro-spinal 
fluid in tuberculosis is attributable to wasting of the brain, a hydrocephalus 
ex vacuo, and in some cases to passive congestion and serous transudation, 
due to feeble circulation, or obstructed flow from the pressure of bronchial 
glands on the vessels within the thorax, as already stated. 

Tubercles were present in the pia mater in three cases : in two with 
fibrinous exudation ; in the other without fibrin or other evidence of in- 
flammation. 

Symptoms The symptoms in tuberculosis of children arise in part 

from the diathesis, and in part from the tubercles. Before the period of 
tubercles, there are signs of failing health, such as loss of appetite, flabbi- 
ness of the soft parts, or emaciation, lassitude, and loss of strength. These 
symptoms continue after the formation of tubercles, and increase. 

The features are ordinarily pallid, but during the paroxysms of fever, 
to which tubercular patients are subject, they may be flushed. Lividity 



132 TUBERCULOSIS. 

of the features, due to imperfect decarbonization of the blood, occurs, if 
there are enlarged bronchial glands which compress the vessels within the 
thorax, or if there is extensive pulmonary tuberculization, or pulmonary 
tuberculization, whether extensive or not, which is complicated by capil- 
lary bronchitis or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness, and 
becomes dry and rough. In some patients there is, at times, general or 
partial furfuraceous desquamation of the skin, due to exaggerated develop- 
ment of the epidermis. Children, like adults, notwithstanding the general 
dryness of the surface, are liable to perspirations at night and in sleep. 
This symptom is less frequent at the commencement than at an advanced 
period, and in acute than in chronic cases, in the very young, namely, 
those under three or four months, than in older children. It is more 
abundant about the head and limbs than elsewhere, and is sometimes con- 
fined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed circu- 
lation, in consequence of compression of the thoracic vessels by enlarged 
lymphatic glands ; in other cases it is due to diminished plasticity of the 
blood, a result of the tubercular cachexia. The latter is the more com- 
mon cause. It is not an important symptom, on account of the small 
amount of serous transudation, and the character of the parts in which it 
occurs. 

Emaciation, already alluded to, is early, constant, and progressive. 
Under the age of six or eight months it is less marked than in older chil- 
dren, many preserving considerable rotundity of features and form even in 
advanced tuberculosis. The failure of the strength corresponds in amount 
and progress with the emaciation. Slight at first, and exhibited only by 
a degree of lassitude, it gradually increases, till for weeks before death the 
little patient is fatigued by the ordinary muscular movements, and is dis- 
posed to keet quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis, or tuberculosis complicated by 
severe inflammation, there may be agitation and delirium, especially at 
night. 

In most patients the mucous membrane of the buccal cavity presents its 
normal appearance, with the exception of a moist fur upon the tongue, 
and a paler hue than normal of its surface generally. In acute tuber- 
culosis, and in cases complicated by inflammation, the tongue is sometimes 
dry and brown. The appetite may be normal till the close of life, or it is 
poor or changeable. Occasionally it is increased, although the disease is 
progressing. The bowels are regular or relaxed. Diarrhoea may be a 
prominent symptom, even when there are no intestinal tubercles or ulcer- 
ation. Meteorism and fulness of the abdomen are common. 

Fever, constant, but usually with evening exacerbation, is rarely absent. 



SYMPTOMS. 133 

It continues for weeks or months. During the exacerbation the pulse rises 
to 120, 140, or even to 180 beats per minute, and there is a corresponding 
exaltation of the temperature, which in the latter part of the day, without 
inflammatory complication, ranges from 100° to 102° or 103°. The fever 
is a symptom of diagnostic value as regards the nature of the disease, 
though it does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special symptoms, 
due to tuberculization of the different organs. In young children, on 
account of the fact already referred to, namely, the tendency to a generali- 
zation of tubercles, there is apt to be a blending of the symptoms which 
arise from different organs, but with care it is not difficult in most in- 
stances to isolate and refer them to their proper source. The following 
are the symptoms which arise from tuberculization of the more important 
organs. 

Excephalon The symptoms produced by tubercles of the encepha- 

lon vary according to their seat and size, and the structural changes in 
surrounding parts to which they give rise. Meningeal tubercles, which 
are located for the most part in the meshes of the pia mater, and by 
preference along the course of the small arteries, are ordinarily small, 
not more than a line in diameter, and they may remain latent for a con- 
siderable time. In the majority of cases, however, they sooner or later 
cause meningitis, the symptoms of which are well known and need not be 
described. But tubercles in this situation do sometimes give rise to symp- 
toms when there is no meningeal inflammation. They occasion congestion 
of the surrounding vessels, and serous transudation, and, if developed on 
the under surface of the pia mater, they may produce symptoms by en- 
croaching upon and irritating the brain ; for they are sometimes so much 
imbedded in the convolutions that careful examination is required in order 
to determine that they are meningeal, and not cerebral. Among these 
symptoms may be mentioned headache, frontal or occipital, sometimes 
intermittent, nausea, melancholy, and in certain cases the symptoms pro- 
duced by the serous transudation. 

The symptoms of cerebral are in part similar to those of meningeal 
tubercles, but in most cases others of a neuropathic character are present, 
which serve for differential diagnosis. The differences as regards the 
symptoms of different patients affected with cerebral tubercles are attri- 
butable in part to the fact that their size and rapidity of growth vary, but 
more to the difference in their seat ; for any part of the brain may be the 
seat of tubercles, though certain portions, as the cerebellum, are more fre- 
quently affected than others. 

The child with cerebral tubercles is quiet, but irritable and easily ex- 
cited. Delirium is not common, but many before the close of life exhibit 
a degree of mental dulness. The headache, common in cases of cerebral 
as well as meningeal tubercles, may be nearly general, or it is frontal, 



134 TUBERCULOSIS. 

parietal, or occipital, according to the seat of the tubercles. It is often 
lancinating, often intermittent. 

Clonic convulsions occur towards the close of life. Exceptionally they 
are among the earliest symptoms. Observations have failed to establish 
any relation between the seat of the tubercles and the localization of the 
convulsions. The convulsions may be unilateral, while the tubercles are 
in both hemispheres ; or general, while the tubercles are on one side only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral substance, 
which sometimes occurs immediately around the tubercles, to local conges- 
tions excited by them, and also to serous effusions in the ventricles. The 
convulsions, sooner or later, end in paralysis or coma. 

Contraction, or tonic convulsion of certain muscles, is sometimes ob- 
served. Its most frequent seat is the muscles of the back, and of one or 
both of the lower extremities. It is a late symptom. It occurs in those 
cases in which there is softening around the tubercles, and usually in the 
muscles of the opposite side. 

Paralysis is also a late, but not an infrequent symptom. It is preceded 
by headache, and sometimes, as already stated, by convulsions. Occurring 
as a symptom of tuberculosis of the brain, it is due either to pressure on 
a cranial nerve, or to compression and perhaps softening of the cerebral 
substance. The paralysis may be paraplegic, commencing as feebleness 
of the lower extremities, and increasing until it becomes complete, or a 
more or less complete hemiplegia. In paraplegia due to tubercles of the 
brain, the cerebellum is, as a rule, their seat, while paralysis of one side, 
or of certain muscles of one side, indicates tubercles of the opposite cere- 
bral hemisphere ; but there are exceptions. Paralysis of the third cranial 
nerve gives rise to ptosis, of the sixth to paralysis of the external motor 
nerves of the eye, and therefore to internal strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilatation 
of the pupils, are not infrequent symptoms of tuberculosis of the brain, 
and they possess great diagnostic value. Atrophy of the optic nerve, 
causing amaurosis, sometimes results from tubercles as well as other 
tumors of the brain. Atrophy of this nerve occurs not only when the 
tubercles are so located as to press on the optic tract, in which case the 
explanation is apparent, but also, in certain patients, when the tubercles 
are in other parts of the brain. In these last cases it is thought, by Brown- 
Sequard and others that the imperfect nutrition of the nerve is due to 
contraction of its nutrient vessels, produced by the tubercles through reflex 
action. 

In tuberculosis of the brain, symptoms pertaining to the respiratory, 
circulatory, and digestive systems are either absent or are quite subordi- 
nate to those of a neuropathic character. Slowness of the pulse, with or 



BRONCHIAL GLANDS. 135 

without intermittence, has sometimes been observed, and it is therefore a 
symptom of some diagnostic value. Towards the close of life both pulse 
and respiration are apt to be accelerated. Vomiting, constipation, and 
retraction of the abdomen, which are so common in meningitis, are only 
occasional symptoms. 

Bronchial Glands During the progress of tuberculosis, hyperplasia, 

cheesy degeneration, and softening may occur of various lymphatic glands 
throughout the body, but the bronchial and mesenteric are not only those 
which are most frequently affected, but they are the only glands, unless 
in exceptional instances, which materially increase the danger or give 
rise to special symptoms. These symptoms either have a mechanical 
cause, namely, the pressure exerted by the enlarged glands on contiguous 
parts, or they are due to softening of the glands and consecutive inflam- 
mation and ulceration. 

The following are the principal symptoms due to compression. Some of 
them are not infrequent; others are rare. Compression of the pulmonary 
veins retards the flow of blood from the lungs to the left auricle, giving 
rise to congestion, and, in extreme cases, oedema of the lungs, with san- 
guineous extravasations into the lung-substance, congestion of the right 
cavities of the heart, hepatic veins, and of the systemic capillaries gene- 
rally. Compression of the pneumogastric nerve, or of the recurrent laryn- 
geal, which is the motor nerve of the laryngeal muscles, modifies the voice, 
and produces a cough which is apt to be spasmodic. The cough resem- 
bles that of pertussis, and has been mistaken for it, but it is not so violent 
or protracted. The voice, clear and natural at first, becomes by degrees 
hoarse or feeble from deficient innervation of the laryngeal muscles. 

An enlarged gland, or mass of glands, lying against the trachea or one 
of the bronchial tubes (this may occur with tubes up to the third or fourth 
division), and pressing its walls inward, obviously obstructs more or less 
the current of air. If there is considerable obstruction, a loud sonorous 
rale is produced, which is heard distinctly at a distance from the chest, 
obscuring other rales. It is loudest when the patient is agitated, and it 
sometimes intermits. Feeble respiratory murmur, dyspnoea, and a cough 
are not infrequent in bronchial phthisis. Diminished intensity of the 
respiratory murmur is general or partial, according to the seat of the com- 
pression. It has been most frequently observed at the summit of the lungs. 
In certain patients this symptom is not constant, the respiration being for 
a time feeble and then normal. The dyspnoea may be a prominent and 
distressing symptom, the alas nasi dilating, and the infra-mammary region 
sinking with each inspiration. The cough which occurs when a gland 
presses on the trachea or bronchial tube, is due to the tracheitis or bron- 
chitis to which the pressure gives rise. If ulceration occur at the point of 
pressure, the cough continues as long as the ulcer remains. Compression 
of the large veins within the thorax, which return blood from the head 



136 TUBERCULOSIS. 

and upper extremities, causes more or less congestion of these parts, with, 
perhaps, transudation of serum in the subcutaneous connective tissue, and 
within the cranium. Rarely a softened gland by ulceration gives rise to 
other symptoms than those mentioned, namely, hemorrhage by ulceration 
into a vessel, or pleuritis or pneumonitis if the ulceration is towards the 
lungs. 

Improvement in the condition of the patient affected with bronchial 
phthisis is not unusual. It may be permanent, but in most patients it is 
temporary, so that in a few weeks or months the symptoms are as severe 
as before. The improvement is due to softening and elimination of a 
gland which had given rise to symptoms by its mechanical effect, or by 
the inflammation which it had excited. 

Physical Signs. — These are absent or obscure in the incipient disease, 
when the glands are small, and they are most marked in those cases in 
which the glands are so large as to press on the thoracic walls, since the 
glands then become the medium for the transmission of sounds to the ear. 
The part of the thorax against which they most frequently press is the 
dorsal vertebras, from the first to the sixth, and each side of the vertebras, 
and less frequently the upper third of the sternum. The physical signs 
are dulness on percussion over the interscapular space, and perhaps, though 
to a less extent, over the upper part of the sternum, and bronchial respi- 
ration in the same situations. Occasionally a bruit can be detected, due 
to the pressure of a gland on one of the large vessels of the chest. 

Lungs A cough is one of the earliest and most persistent of the symp- 
toms of pulmonary tuberculosis. It is so rarely absent, that those of 
largest experience do not meet with more than one or two such cases. It 
varies in severity and frequency. If the tuberculosis is acute and its 
course rapid, the cough, even from its commencement, is frequent, so as to 
weary the patient and deprive him of needed rest. But in ordinary cases, 
namely, when the disease is chronic, the cough commences gradually, at- 
tracting little attention by its infrequency, but becoming more frequent 
and painful as the malady advances. 

Ordinarily the cough is dry in the first weeks or months, but it becomes 
looser in the course of the disease, from the greater amount of bronchial 
inflammation. In exceptional instances the cough has a spasmodic charac- 
ter, like that produced by pressure of an enlarged bronchial gland on the 
pneumogastric or recurrent laryngeal nerve. This occurs from the accu- 
mulation of viscid mucus in one or more of the bronchial tubes, usually in 
dilated portions of them, from which it is with difficulty expectorated. 

The respiration in pulmonary tuberculosis is accelerated in proportion 
to the degree of tuberculization. Tuberculization of a considerable part 
of both lungs gives rise to dyspnoea, especially when, as is ordinarily the 
case, bronchial, pulmonary, or pleuritic inflammation has supervened. 
Pneumonitis or pleuritis gives rise to the expiratory moan, and as these 



PHYSICAL SIGNS. 137 

inflammations, when induced by tubercles, are protracted, this symptom 
may continue for weeks or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of pul- 
monary tuberculosis, but in the confirmed disease it is a pretty constant 
attendant of the cough. Haemoptysis is also rare under the age of six 
years, and less frequent subsequently than in the adult. It is most apt to 
occur in those cases in which there is already passive congestion of the 
lungs, produced by the pressure of enlarged bronchial glands in the man- 
ner already described. Patients old enough to make known the subjective 
symptoms, sometimes complain of fugitive pains under the sternum or 
between the shoulders. 

In young children the physical signs of incipient pulmonary tubercu- 
losis are wanting, or are so obscure as not to be readily recognized. This 
is due to the small size and dissemination of the tubercles. In older 
children the physical signs appear early, and are readily recognized, 
because, as a rule, the tubercles are aggregated, and are more frequently 
at the apices of the lungs than elsewhere, as in the adult. In the ad- 
vanced disease, whether in infancy or childhood, when inflammation and 
more or less destruction of the lung-substance have occurred, the physical 
signs, so far from being obscure, enable us in most cases, in connection 
with the history, to make an immediate and positive diagnosis. 

In young children affected with pulmonary tuberculosis the irregular 
and imperfect expansion of the lungs produces by degrees changes in the 
shape of the thorax, which are apparent on inspection. In some, the lungs 
being habitually imperfectly inflated, the obliquity of the ribs is increased, 
and the thorax consequently elongated, while its antero-posterior and trans- 
verse diameters are diminished. This obviously increases the convexity 
or arch of the diaphragm, so that this muscle sometimes lies against the 
thoracic walls as high as the ninth or even eighth rib. If the costal car- 
tilages are yielding, there is anterior flattening of the chest and depression 
of the sternum ; if they are firm, on account of the more advanced age 
the chest remains circular. 

Another shape of the thorax is not infrequent in feeble tubercular 
children, especially infants, who have suffered from repeated attacks of 
bronchitis. It occurs also in the non-tubercular, if the conditions which 
favor it are present. The conditions are, on the one hand, feebleness of 
the patient, with diminished force of respiration and impaired resiliency 
of the ribs ; and, on the other, obstruction by mucus of one or more of 
the bronchial tubes. Occlusion more or less complete, of a bronchial tube, 
and consequent obstruction to the current of air, produce a corresponding 
degree of collapse in the proportion of lung to which the tube leads. The 
portions which collapse are, in most cases, the lower lobes, and the thin 
anterior margins of the upper lobes. This causes lateral depression of the 



138 TUBERCULOSIS. 

lower ribs, except such as are pressed outward by the abdominal viscera, 
and an anterior projection of the lower part of the sternum. The shape 
of the thorax in these cases differs from that in rachitis, in the fact that 
the lateral depression does not extend to the upper ribs, nor does the upper 
part of the sternum project. 

Certain precautions should be observed in examining the chest by per- 
cussion and auscultation. The child should sit or recline, with the arms 
and shoulders in the same position, and the axis of the trunk straight. 
Inclination of the trunk to either side, raising or depressing a shoulder 
may produce an appreciable difference in the two sides as regards the 
physical signs. Percussion of the two sides should be practised at the 
same stage of respiration. A slight difference in the degree of resonance 
does not afford proof of disease, unless it is observed at different exami- 
nations ; for, in feeble children, it often happens that all portions of the 
lungs do not expand alike, so that where we have noticed slight dulness 
at one visit, it may by the next have disappeared, or even at the same visit 
if forcible inspirations are excited. 

The physical signs ascertained by palpation, auscultation, and percussion 
are, as in the adult, vocal fremitus, bronchial respiration, bronchophony, 
and dulness on percussion. In those cases in which the tubercles are 
mainly at the apices of the lungs, diminished expansion of the infra-cla- 
vicular region is observed during inspiration, and this part of the thoracic 
wall is permanently depressed, so that the clavicles are unusually promi- 
nent. If there is emphysema, this flattening does not occur, or is slight. 
Dulness on percussion, though more frequently observed in the infra- 
clavicular region than elsewhere, may be present in different isolated 
places. If pneumonia supervene, the dulness not infrequently extends 
over a considerable part of one lung. The cracked-pot sound is often ob- 
served on percussion, but it possesses no diagnostic value. It can be pro- 
duced, when there is no pulmonary disease, by percussing over a bronchus. 

Bronchial respiration and bronchophony are important signs, as indi- 
cating solidification of the lung, but they do not show whether the solidi- 
fication is tubercular or pneumonic, or the two conjoined. This must be 
determined by the history of the case, the extent of surface over which 
these signs are heard, and their persistence. When the tubercles begin to 
soften, and the lung-tissue breaks up, moist rales appear, often hoarse and 
gurgling, obscuring the bronchial respiration. A cavity in the lung, or 
pneumothorax, is attended by the same physical signs as in the. adult. 

Pleura Little need be said in reference to the symptoms and physical 

signs of tuberculosis of the pleura, since this affection is in most instances 
associated with tuberculosis of the lungs, and is not distinguishable from 
it. But now and then the pleural tubercles are numerous and large, giving 
rise to symptoms, while those of the lungs are small, few, and without 
symptoms, or attended by symptoms which are quite subordinate. Either 



DIAGNOSIS. 139 

the costal or visceral portion of the pleura may be the seat of tubercles. 
They are developed directly under the pleura, or upon its free surface. 
They are very apt to occur in the newly formed connective tissue which 
results from pleuritis. Those located upon the free surface, or under the 
costal pleura, rarely soften, while those under the visceral pleura some- 
times soften and cause ulceration. Occasionally numerous aggregated 
tubercles form a firm continuous layer upon the surface of the pleura, pre- 
venting, if upon the visceral pleura, full expansion of the lung. This may 
give rise to a degree of dulness on percussion, and feebleness of the respi- 
ratory murmur. Ordinarily, however, in this form of tuberculosis, the 
symptoms and physical signs, so far as any are observed, are due to the 
pleuritic inflammation which the tubercles excite. 

Stomach and Intestines The symptoms in tuberculosis of the 

stomach and intestines vary according to the seat and stage of the tuber- 
cles. 

Tubercles, whether gastric or intestinal, are not at first accompanied by 
symptoms, or the symptoms are obscure and ill-defined. Symptoms arise 
when inflammation occurs in the adjacent tissues. Diarrhoea is one of the 
most common and persistent of the symptoms. The alvine discharges are 
brown and thin, and sometimes, in advanced cases, very offensive. They 
may be streaked with blood which has escaped from the ulcers. Intestinal 
tubercles, developed immediately underneath the peritoneal coat, some- 
times cause local peritonitis, usually of little extent. This gives rise to 
circumscribed pain, tenderness, and more or less meteorism. 

Diagnosis It is evident from the foregoing description of symptoms 

that the diagnosis of incipient tuberculosis is much more difficult in chil- 
dren than adults. Before commencing the examination, it is advisable to 
learn the hereditary tendencies of the family and the history of the pa- 
tient, especially as regards antecedent diseases or debilitating agencies, 
and the duration of the symptom. 

Tuberculosis of the encephalon is diagnosticated with more difficulty 
than that of the thoracic or abdominal organs ; but certain of these organs 
are ordinarily tubercular at the same time, and the knowledge of the fact 
that they are affected aids in the diagnosis of the disease of the brain or 
its meninges. Among the symptoms which possess diagnostic value may 
be mentioned cephalalgia and more or less fever, with exacerbations in the 
commencement of the disease, and, at a more advanced period, strabismus, 
inequality or irregular action of the pupils, impairment of vision, retrac- 
tion of the head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms are 
requisite, in order to determine whether they arise from intra-cranial 
tubercles, or from congestion of the brain caused by obstruction in the 
venous circulation by the pressure of enlarged bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still small, is 



140 TUBERCULOSIS. 

necessarily uncertain, on account of the absence of symptoms. "When 
they have increased in size and are so located as to press on the pneumo- 
^astric or recurrent laryngeal nerve, producing the spasmodic cough already 
described, the differential diagnosis between that disease and pertussis may 
be made by attention to the following faets : Bronchial phthisis occurs 
singly, and is non-contagious, while pertussis occurs as an epidemic, and 
with evidences of contagion. There are no successive stages, namely, those 
of catarrh, paroxysmal cough, and decline, as in that disease, and the cough, 
though paroxysmal, is short, and without hoop or vomiting. 

In feeble children, with inherited tubercular diathesis, emaciation, sweats, 
and a chronic cough, with the absence of pulmonary symptoms, should 
excite suspicions that the bronchial glands are involved. The evidence 
is almost conclusive if the cough becomes paroxysmal, and there is a loud, 
persistent, tracheal, or bronchial rale. 

In certain of the patients affected with this form of tuberculosis, we have 
seen that the prominent symptoms are due to compression of one or more 
of the large vessels in the chest. Compression of these vessels, and conse- 
quent retarded circulation, may be confidently referred to enlarged bron- 
chial glands, since aneurism, carcinomatous or other tumors, which would 
produce a similar result, are very rare before puberty. Sometimes the diag- 
nosis is rendered certain by the physical signs observed by auscultation, 
and percussion over the sternum and the interscapular space. The condi- 
tion of the external glands should also be observed, as those of the axilla, 
neck, and groin. 

The diagnosis of pulmonary, though more readily made than that of 
intra-cranial and bronchial tuberculosis, is often difficult and uncertain. 
This is, in part, explained by the fact that the tubercles are so frequently 
disseminated, while emaciation and a chronic cough are not infrequent 
from other causes than tubercles. Rachitis, intestinal worms, dentition, 
simple tracheal or bronchial inflammation, may be attended both by a 
chronic cough and emaciation. Caution is therefore requisite in order to 
avoid a grave error in diagnosis. Precipitancy in the diagnosis of doubt- 
ful cases is worse than indecision, and it is often best to postpone an ex- 
pression of opinion as to the nature of the disease till the case has been 
observed for a few days. 

The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based, have already been suffi- 
ciently pointed out. It is difficult, in fact in certain cases impossible, to 
discriminate between simple cheesy pneumonia and cheesy pneumonia 
which has ended in the formation of tubercles. The patient has an attack 
of catarrhal pneumonia ; but, instead of absorption of the inflammatory 
product, cheesy infiltration occurs, and the lung in places becomes infil- 
trated with pus, softens, and breaks down. The patient presents the symp- 
toms and physical signs of phthisis. He may recover after a protracted 



PROGNOSIS. 141 

sickness, or may die. The disease may, and often does, remain a pneu- 
monia; but this is a condition of the lungs which favors the development 
of tubercles, and in a certain proportion of cases tubercles do form in the 
last weeks of life. Though the differential diagnosis in such cases between 
simple pneumonia and tuberculosis supervening on pneumonia is impos- 
sible, practically the discrimination is unimportant, as the same treatment 
is required. 

Advanced pulmonary tuberculosis, except when it supervenes upon 
pneumonia, can in most instances be readily diagnosticated by a careful 
examination. Still, it is to be recollected, as already pointed out, that 
certain of the symptoms and physical signs, which occurring in the adult 
would afford almost positive proof of pulmonary tuberculosis, not infre- 
quently have a different origin in children. 

The diagnosis of tubercles in the abdominal organs is facilitated by the 
presence of symptoms which indicate at the same time tuberculosis of the 
lungs. Among the chief diagnostic signs of tuberculosis of the peritoneum 
may be mentioned meteorism and a degree of tenderness on pressure, but 
there is danger of mistaking the tympanitic state of the intestines common 
in ill-nourished infants and the rachitic, or the fulness due to enlarged 
spleen or liver, for that occasioned by peritoneal tuberculization, and vice 
versa. The history of the case, and a careful examination of accompany- 
ing symptoms, and the shape and feel of the abdomen, usually suffice to 
establish the diagnosis. In simple gaseous distension of the abdomen there 
is an absence of the symptoms, general and local, which attend tubercu- 
losis ; rachitis occurs at an earlier age than peritoneal tuberculosis, and 
digital examination, aided by percussion, enables us to diagnosticate en- 
largement of the liver or spleen. 

Tubercular enlargement of the mesenteric glands cannot be positively 
diagnosticated when they are small. When they have attained such a size 
that they can be felt through the abdominal walls, palpation in connection 
with the history and symptoms of tuberculosis suffices to establish the 
diagnosis. The glandular tumors can be diagnosticated from other tumors 
by the fact that they are tender on pressure, and occupy the umbilical 
region, while fecal tumors are not tender, and are located in the iliac or 
lumbar region. Gastro-intestinal tuberculosis cannot be positively diag- 
nosticated. Protracted diarrhcea, or frequent attacks of diarrhoea, not 
readily controlled by medicine, and occurring in tubercular cases, are 
probably associated with intestinal ulceration ; but in only a certain pro- 
portion of cases of ulceration are there also tubercles in the walls of the 
intestines, as we have seen above. 

Prognosis — Death is the ordinary result of tuberculosis in the child, 
as it is in the adult ; but now and then one recovers. Hospital statistics 
show that the average duration of the disease is from three to seven 
months. Under favorable circumstances it is more protracted, even to 



142 TUBERCULOSIS. 

two or three years. Those succumb soonest who inherit a strongly marked 
tubercular diathesis, live in damp, dark, and ill-ventilated apartments, 
and whose diet is scanty or of poor quality. Therefore in the poor quarters 
of the city tuberculosis presents a worse form and pursues a more rapid 
course than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequency of cough, 
with respiration, pulse, and temperature nearly normal. Such symptoms 
may afford hope of recovery with judicious regimenal and therapeutic 
measures. On the other hand, if the symptoms are grave, death is in- 
evitable, unless in bronchial phthisis, in which, even when there is 
considerable urgency of symptoms, the offending gland is sometimes elimi- 
nated by softening and ulceration, and the patient improves temporarily, 
if he does not ultimately recover. Complete and permanent recovery is, 
however, quite exceptional. 

Death in tuberculosis of children may occur from exhaustion induced 
by the general disease, or from the local effect of the tubercles. Thus, in 
intra-cranial tuberculosis it may result from coma; in pulmonary tuber- 
culosis, from dyspnoea, though more frequently from exhaustion ; in that 
of the bronchial glands, from coma, dyspnoea, exhaustion, or even from 
hemorrhage ; in that of the abdominal organs, from peritonitis or pro- 
tracted diarrhoea. 

Treatment. Prophylactic Since an infectious principle generated 

in cheesy substance is the common cause of the development of tubercles, 
it is evident that measures which tend to prevent the occurrence of this 
substance are prophylactic of tuberculosis. And since, in children, cheesy 
matter, in most instances, is a product of strumous inflammations, the 
anti-strumous remedies are demanded in the prophylactic as well as cura- 
tive treatment of tuberculosis. Therefore, the strumous child should be 
watched with great care, and such measures be employed as are calculated 
to invigorate its system. If the mother belongs to a decidedly tubercular 
family, or gives the history of scrofula in her childhood, it is better that 
she do not suckle her infant, but employ a healthy wet-nurse. Children 
who are weaned should have plain, but nutritious and easily digested diet, 
a part of which should be milk. Residence in an airy and salubrious 
locality, out-door life, a scrupulous avoidance of exposure, by which a cold 
might be contracted, are important, in order to the continued latency of 
the diathesis. 

Loss of flesh or appetite, or other evidences of failing health, indicate 
the need of other measures of a therapeutic character. Alcoholic stimu- 
lants should now be allowed three or four times daily in milk ; cod-liver 
oil, with half its quantity of syrup of the lactophosphate of lime, to which 
the syrup of the iodide of iron is added, will be found useful for these 
cases, as it is in the ordinary forms of scrofula. The various bitter pre- 



ETIOLOGY OF SYPHILIS. 143 

parations containing iron, as the citrate of iron and quinine, elix. calisaya 
bark with iron, etc., should by employed, when, for any reason, cod-liver 
oil is not tolerated. By the employment of such precautionary measures 
as soon as indicated, multitudes of children might be saved from tuber- 
culosis who now perish. 

Curative. — The medicinal agents which are required in ordinary cases 
have been already mentioned, namely cod-liver oil, iron, sometimes the 
vegetable tonics, and alcoholic stimulants. The oil may be given in emul- 
sion to disguise the unpleasant flavor, or, which I prefer, mixed with half 
its quantity of syrup of the lactophosphate of lime, as recommended for 
the treatment of scrofula. 

If the cod-liver oil is not tolerated, or if it impairs the appetite, it 
should be discontinued. In cases of diarrhoea it is of little or no benefit, 
and may do harm. Under such circumstances patients sometimes do 
better with simple regimenal measures, aided by alcoholic stimulants, and 
one of the least unpleasant of the tonics, as wine of iron or the calisaya 
bark. The regimen already recommended for prevention is also required 
as a part of the curative treatment. 

Certain modifications of treatment are demanded on account of the 
localization of the tubercles. Intra-cranial tuberculosis, as soon as diag- 
nosticated, should be treated by pretty decided doses of iodide of potas- 
sium, though, unfortunately, there is little prospect of improvement. The 
glandular disease, whether bronchial or mesenteric, requires the iodide 
of iron, with or without that of potassium. Pneumonitis or pleuritis, so 
frequent a complication of pulmonary tuberculosis, requires emollient poul- 
tices, with moderate counter-irritation, and the judicious use of opiates 
with stimulants. The peritonitis occurring in abdominal tuberculosis, 
which is usually circumscribed, is best treated by fomentations and poul- 
tices, with opiates, and the diarrhosa by subnitrate of bismuth and chalk, 
five to ten grains of each, or the bismuth with Dover's powder, or a more 
active astringent. 



CHAPTER IV 

SYPHILIS. 



Syphilis in infancy and childhood presents itself under two forms, 
namely, the congenital and acquired ; the former is the more frequent. 

Etiology — Congenital syphilis may be derived from either father or 
mother. Either parent, having previously had syphilis, may transmit it 
to the offspring, although at the time free from syphilitic symptoms. The 
mother healthy at the time of conception, but infected with syphilis prior 



144 SYPHILIS. 

to the eighth month of gestation, may communicate the disease to the 
foetus ; syphilis contracted in the eighth or ninth month does not affect 
the foetus. If both parents have syphilis, the infant is almost necessarily 
syphilitic ; on the other hand, if only one parent is affected, the infant 
may or may not be contaminated. Sometimes, with such parentage, a 
part of the children are syphilitic, and a part healthy. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or bubo ; 
or it may be derived from certain of the secondary lesions. Inoculation 
by primary lesions may occur at the birth of the infant, from a syphilitic 
sore in the vagina or upon the vulva of the mother ; inoculation in this 
manner is, however, rare. Children may also receive the virus from pri- 
mary lesions on the persons of nurses or companions. Infection in this 
manner is sometimes accidental, and sometimes the result of criminal con- 
duct. A chancre on the breast of the wet-nurse not very infrequently 
communicates syphilis to the nursling. 

The contagiousness of "secondary manifestations," for a long time 
doubted, is now fully established. Syphilis may be communicated by the 
secretion or exudation of a mucous patch, or a secondary sore. Hence 
the danger of lactation by unhealthy wet-nurses, though they present no 
symptoms of recent syphilis. Excoriations or sores upon the nipple or 
breast of an infected wet-nurse may communicate the disease to the nurs- 
ling ; and, on the other hand, mucous tubercles or fissures upon the lips or 
tongue of the infected infant may be the means of contaminating a healthy 
wet-nurse. Many such cases are now contained in the records of medi- 
cine. Vaccination by means of the scab is also a mode by which consti- 
tutional syphilis may be communicated. For further particulars in refer- 
ence to this subject the reader is referred to our remarks on vaccination. 

Clinical History. — The effects of the syphilitic poison upon the de- 
velopment of the foetus, and the development and health of the infant, are 
different in different cases. The foetus, under the influence of the poison, 
often ceases to grow, shrivels, dies, and is expelled, long before term, or it 
may be born alive, but prematurely, and showing clear evidences of the 
disease, as soon as it comes into the world ; or, again, it may be born at 
term, but dead. So frequently is syphilis a cause of non-viability, that, 
as Trousseau has remarked, this disease should be suspected as the cause, 
whenever a woman repeatedly aborts. Abortion from syphilis commonly 
occurs at or about the sixth month of gestation. In these cases in which 
the foetus dies from syphilis there is often placental syphilitic disease, 
namely, an undue growth of cells in the villi, which, compressing the ves- 
sels, gives rise to fatty degeneration, and prevents the requisite interchange 
between the maternal and foetal blood. (Herring, Frankell.) Frankell 
designated the change " granulation-cell hypertrophy of the placental 



CLINICAL HISTORY. 145 

villi." Virchow, in one case, found a gummy tumor in the maternal por- 
tion of the placenta. 

When a foetus destroyed by syphilis is expelled, it is apt to present a 
macerated appearance, the cuticle being detached over large patches of 
surface, and in other parts raised in blebs, with a thin, puriform, and 
offensive fluid underneath; the liver is occasionally indurated, and ab- 
scesses with spots of inflammation are sometimes observed in the thymus 
gland ; the amniotic fluid is offensive, turbid, and of a greenish or greenish- 
brown appearance. 

If the foetus, in which syphilitic manifestations have begun to occur, 
has reached a viable age, and is born alive, it is small and imperfectly 
developed, often shrivelled and senile in appearance. The skin looks 
unhealthy, and it may exhibit a distinct rash. Bouchut saw a seven and 
a half months' infant born alive, with an eruption of a copper color upon 
the legs and arms, and onyxis upon the fingers and toes. The bullae of 
pemphigus are also not infrequent upon the skin at birth, or they appear 
within a few days, two or three, after birth. The smallest are about the 
size of a split pea ; but many are considerably larger ; the largest consist 
of two or more which have coalesced. They contain a thin, greenish, 
purulent matter, and appear most frequently upon the palms of the hands 
and soles of the feet, but also in severe cases upon the face and over the 
surface of the body. Recently I was able to diagnosticate syphilis in 
an infant within a day after birth, by its small size and feebleness, and 
the appearance of large blebs of pemphigus upon its hands, feet, fingers 
and toes, over which the skin soon broke, leaving troublesome and bleed- 
ing sores ; coryza commenced about the twelfth day. The parents seemed 
healthy, but I was enabled to trace the syphilitic taint to the mother. 
Xon-syphilitic pemphigus, the result of cachexia, sometimes appears soon 
after birth, but its primary and usual seat is around the neck, and upon 
the body. 1 have known it to appear within the first week of life, and 
end fatally by the close of the second week. I have not found it difficult 
to distinguish it from syphilitic pemphigus by the history of the family, 
and its absence from the palmar and plantar surfaces of the hands and 
feet. Condylomata, mucous patches, and stains of a copper color are the 
principal syphilitic affections, besides pemphigus, which have been ob- 
served at birth on the bodies of contaminated infants. It is stated that 
M. Cullerier, in ten years' attendance at the Hopital de Lorraine, met 
only two cases of syphilitic manifestations at birth, and Victor de Meric 
only two cases in forty-six infants, who were affected with congenital 
syphilis (Bumstead) ; but in the practice of others a larger proportion 
have exhibited symptoms at birth. Ordinarily the period in which con- 
genital syphilis is first revealed by symptoms is between the fifteenth and 
fortieth days. Rarely the manifestation of the disease is delayed several 
10 



146 SYPHILIS. 

months. M. Diday ascertained the time of the commencement of symp- 
toms in 158 cases as follows : — 

Before the completion of one month after hirth, in . .86 

" " two months " . . .45 

" three " " ... 15 

At four months ......... 7 

" five 1 

" six " 1 

" eight " 1 

" one year ......... 1 

" two years ......... 1 

In cases of tardy commencement of syphilitic symptoms it is probable 
that the poison has been partially eradicated from the affected parent by 
appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be im- 
paired when the local manifestations of syphilis appear, or soon after. The 
system gradually wastes ; the skin loses its fresh and healthy appearance, 
and becomes sallow, and, after a time, more or less wrinkled; the features 
become pinched and contracted, and wear a sad expression. M. Diday says : 
" Next to this look of little old men, so common in new-born children 
doomed to syphilis, the most characteristic sign is the color of the skin." 
Trousseau thus describes this discoloration of the surface : " Before the 
health becomes affected, the child has already a peculiar appearance ; 
the skin, especially that of the face, loses its transparency ; it becomes 
dull, even when there is neither puffiness nor emaciation ; its rosy color 
disappears, and is replaced by a sooty tint, which resembles that of Asiatics. 
It is yellow, or like coffee mixed with milk, or looks as if it had been 
exposed to smoke ; it has an empyreumatic color, similar to that which 
exists on the fingers of persons who are in the habit of smoking cigarettes. 
It appears as if a layer of coloring had been laid on unequally ; it some- 
times occupies the whole of the skin, but is more marked in certain 
favorite spots, as the forehead, eyebrows, chin, nose, eyelids — in short, the 
most prominent parts of the face ; the deeper parts, such as the internal 
angle of the orbit, the hollow of the cheek, and that which separates the 
lower lip from the chin, almost always remain free from it. Although the 
face is commonly the part most affected, the rest of the body always par- 
ticipates more or less in this tint. The child becomes pale and wan." 

The infant whose system is profoundly affected by syphilis rarely smiles, 
and its voice is feeble and plaintive ; its frequent whimpering cry is quite 
characteristic. 

Coryza is one of the earliest and most constant of the local affections 
which occur in infantile syphilis. It is slight at first, attracting little 
attention from the parents, who are not aware of its significance, and 



MUCOUS PATCHES. 147 

usually attribute it to a slight cold ; but it gradually increases. It gives 
rise to a secretion from the Schneiderian membrane, at first thin, but 
which becomes more consistent, and is attended by the formation of scabs. 
The thickening of the mucous membrane, in consequence of the inflam- 
mation and the presence of crusts, narrows the passage through the nostrils 
so as to produce snuffling respiration, and sometimes render nursing diffi- 
cult. In severe cases respiration through the nostrils is almost wholly 
prevented, so that death may occur from inanition, unless the breast is 
milked into the infant's mouth, or it is fed with a spoon ; but, ordinarily, 
even in grave coryza, it continues to nurse, though obliged often to release 
its hold of the nipple to obtain breath. It is when coryza begins to inter- 
fere with lactation that it first alarms the parents. The inflammation at 
the same time may affect the throat and larynx, causing hoarseness of the 
voice. Ulceration of the Schneiderian membrane and the adjacent car- 
tilage or bone is rare in infancy or childhood, although cases occur which 
are even attended with more or less flattening of the nose. Diday believes 
that the discharge which accompanies coryza is in great part due to mucous 
patches developed on the Schneiderian membrane. The upper lip, over 
which the discharge flows, becomes red, excoriated, and more or less 
incrusted. The coryza, in most cases, coexists with other local syphilitic 
affections. Occasionally it occurs alone, and is the only evidence of the 
presence of the specific taint, except such as is afforded by the mal-nutri- 
tion and general appearance of the patient. 

Mucous patches occur in most patients. They are developed either 
upon the mucous surfaces, or upon parts of the skin which are thin and 
exposed to friction, and such as are moistened by secretion or transudation 
from the vessels underneath. The most common seat of mucous patches 
is at the termination of mucous canals ; but in infancy, on account of the 
peculiar delicacy of the skin, they may occur upon almost any part of the 
cutaneous surface. They are most common, however, around the anus, 
upon the vulva, scrotum, umbilicus, labial commissures, in the axilla?, and 
behind the ears. 

Mucous patches upon the skin present a rounded border, and are slightly 
elevated. Their color has been compared to that of the skin which has 
been softened by the prolonged application of a poultice. Erosions and 
cracks sometimes occur in the patches, from which a thin liquid exudes. 

Upon mueous surfaces they are less elevated than upon the skin, and 
are prone to ulcerate. These ulcerations, commencing at the centre, ex- 
tend, and soon the mucous patch disappears, and its site is occupied by an 
ulcer. The ulcer may be circular, oval, elliptical, crescentic, or irregular. 
The arches of the fauces are a common seat of mucous patches. 

Roseola is an occasional symptom of infantile syphilis. " It is distin- 
guished," says Diday, " by patches of a bright rose-color, circumscribed, 
irregularly rounded, of various sizes (most frequently about as large as 



148 SYPHILIS. 

one of the nails) ; appearing, by preference, on the belly, lower part of 
the chest, neck, and inner surface of the extremities." The spots do not 
readily and fully disappear by pressure. 

Pemphigus appearing soon after birth has already been alluded to. Its 
most frequent seat, whether occurring after birth or as a subsequent mani- 
festation, is, as we have stated, the palms of the hands, soles of the feet, 
the fingers, and toes. This eruption commences by a violet tint of the 
skin, and in the course of twenty-four to forty-eight hours a watery fluid 
collects underneath, which soon becomes turbid. The skin peels off, and 
sometimes an angry sore results, which bleeds readily when rubbed or 
pressed. In other and more favorable cases new skin takes the place of 
that which is lost. Pemphigus at birth is a precursor of death, but when 
it appears for the first time some weeks after birth, it is a less unfavorable 
prognostic sign. In cases of recovery it disappears, with proper treatment, 
in two or three weeks. 

Acne, impetigo, and ecthyma are occasionally observed in children 
afflicted with syphilis. The indurated pustules of acne occur most fre- 
quently upon the shoulders, back, chest, and buttocks. The pus is some- 
times absorbed, and in other cases discharged, leaving a small cicatrix, 
which, after a time, disappears. Impetigo appears most frequently upon 
the face, and occasionally upon the chest, neck, axilla, and groins. Un- 
like simple impetigo, the syphilitic impetiginous eruption is surrounded by 
a copper-colored areola. Ecthyma occurs upon the legs and buttocks 
chiefly. It commences as violet-colored spots, which are soon transformed 
into pustules. Ulcers succeed, which, in reduced states of the system, are 
apt to enlarge and endanger the safety of the child. Of the three pustular 
eruptions, acne, according to Diday, is the least serious — indicating a 
''less confirmed diathesis." Ecthyma is the most serious, on account of 
the reduced state of system with which it is apt to be associated. Syphil- 
itic papulse and squamae are rare in infants, but cases have been observed. 
Onychia occasionally occurs, though less frequently than in syphilis of the 
adult. 

Visceral Lesions. — The visceral lesions which occur in the syphilis 
of infancy and childhood are, suppuration in the thymus gland ; gummy 
tumors in certain organs, most frequently the lungs and liver ; increase of 
the connective tissue of the liver, known as syphilitic cirrhosis ; partial 
perihepatitis, with depressions resembling cicatrices on the surface of the 
liver ; peritonitis ; periostitis, with thickening of the bone and exostosis. 

Suppurative inflammation in the thymus gland is not common, or has 
not been frequently observed. When it is present the gland sometimes 
presents its normal appearance externally, and the abscess is only discov- 
ered by incisions. Gummy tumors are white and spheroidal ; some are as 
small or smaller than a pin's head, while others are as large as a pea, or 
even a hazel-nut. I have seen a considerable number of them not as large 



VISCERAL AND OSSEOUS LESIONS. 149 

as a pin's head, in the liver of an infant. Gummy tumors, according to 
Lebert, consist " of loose fibrous tissue, made up of pale elastic fibres, 
inclosing in their large interspaces a homogeneous granular substance, the 
elements of whicfh are less adherent to each other than in deposits of true 
tubercle." Lebert also, with other microscopists, discovered round granu- 
lar cells in these tumors. According to Robin, gummy tumors " are made 
up of rounded nuclei belonging to fibro-plastic cells, or cytoblastions ; of 
a finely granular, semi-transparent, and amorphous substance ; and, finally, 
of isolated fibres of cellular tissue, a small number of elastic fibres, and a 
few capillary bloodvessels." 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of hered- 
itary syphilis the spleen is enlarged. (London Lancet, April 13th, 1867.) 

Infiltration of the liver by fibrous substance was first noticed by Giibler. 
It is not common in the infant. A specimen, showing this lesion, was 
presented to the London Pathological Society in 1866, by Dr. Samuel 
TVilks. The following remarks by Dr. Wilks convey a good idea of the 
appearance and state of the liver in syphilitic cirrhosis : " Having dis- 
sected the bodies of several infants, who have died of congenital syphilis, 
I have found fatty livers, and an inflammation of the capsule ; but in only 
two have I discovered adventitious products of a fibrous character. The 
present example, however, corresponds in every particular with the disease 
described by Giibler. It must be distinguished (at least as far as the 
naked-eye appearance reaches) from the syphilitic disease of adults, of 
which many specimens have been before the Society. In these the organ 
is cicatrized on the surface, and contains distinct nodules of fibrous tissue; 
whilst in the disease of children, as in the present specimen, the whole 
organ is infiltrated by a new material, and it consequently becomes, as 
described by Giibler, hypertrophied, globular, and hard, resistant to pres- 
sure, and even when torn by the fingers, its surface receives no indentation 
from them ; it is also elastic, and when cut, creaks slightly under the 
scalpel. This was the form of disease in the present specimen. It came 
from a syphilitic child, a month old, in whom the liver could be felt 
enlarged during life, and when removed weighed a pound and a half. It 
was smooth on the surface, and so hard that it resembled rather a fibrous 
tumor than a liver. It is seen that the liver in the syphilitic child is 
liable to three distinct pathological processes, namely, gummy tumors, 
cirrhosis or fibroid degeneration, and waxy degeneration. 

Syphilitic perihepatitis and periostitis are more rare in infancy and 
childhood than in adult life, but they occasionally occur. The late Sir 
James Y. Simpson considered peritonitis in the foetus one of the results of 
syphilis, and a cause of its death. 

Osseous Lesions Within the last few years, important discoveries 

have been made in regard to the effect of syphilis upon the nutrition of 



150 



SYPHILIS. 



the bones in children. In 1870, Dr. "Wegner, of Berlin, published his 
observations of the state of the skeleton in twelve syphilitic children, who 
were either stillborn, or who died within a few days or weeks after birth. 
He found clear proof that the syphilitic dyscrasia very frequently disturbs 
the nutrition and produces anatomical changes in the skeleton of the 
foetus. The following are the lesions, clearly referable to syphilis, which 
he observed : Periostitis of long bones, including the ribs ; softening, sepa- 
ration, and sometimes crepitation, at the point of union of diaphysis and 
epiphysis ; chalky concretions and infiltrations along the line of ossifica- 
tion ; fatty degeneration of marrow ; irregular formation and distribution 
of spongy substance in the epiphysis. These lesions were not all observed 
in each case, but they occurred with such frequency, that there could be 
no doubt that they were due to the syphilitic taint of system. Confirmatory 
observations also, in twelve cases, have since been made by Waldeyer and 
Kobner. 1 

Again, there is a syphilitic lesion of the bone in children, which is not 
usually present or has not usually been observed at birth, but is developed 

in the first weeks or months of in- 
FlG * * fancy. The lesion alluded to is a 

circumscribed enlargement of one 
or more bones. This has been 
most frequently observed upon the 
long bones, including the clavicle 
and ribs ; but in certain children it 
occurs upon other bones in addi- 
tion. In some cases it is one of 
the first manifestations of heredi- 
tary syphilis, occurring even sooner 
than the coryza, while in others 
several months elapse before it ap- 
pears. In one case, reported by 
Dr. Bulkley, 2 of this city, it was 
first seen only a few days after 
birth, being perhaps congenital ; 
while in another case, in which the 
enlargement was upon certain pha- 
langes, and which is represented 
in the accompanying figure, it appeared at the age of twelve months. 
When it occurs upon a phalangeal bone, it is designated dactylitis 
syphilitica. 




1 See elaborate paper by R. W. Taylor, M.D., New York Journal of Obstetrics, 
etc., July, 1874. 

2 Rare Cases of Congenital Syphilis, New York Med. Journal, May, 1874. 



OSSEOUS LESIONS. 151 

The enlargement, if upon a long bone, ordinarily begins at or near the 
point of union of the diaphysis with the epiphysis. It is located upon the 
extremity of the shaft which it encircles, and it extends over a part or 
nearly the whole of the epiphysis. It has an elevation of perhaps one- 
half or three-quarters of an inch in typical cases ; its surface is smooth, or 
slightly undulating, and the skin over it, though distended, has its normal 
appearance, and is easily movable, unless ulcerations have occurred. 

These enlargements, which result from the specific inflammation occur- 
ring in the periosteum and the bone, may resolve under proper treatment ; 
but if neglected, and the anti-hygienic conditions are bad, degenerative 
changes may occur, ending in ulceration and destruction of the diseased 
part to a greater or less extent. 

Though these bone enlargements, whenever observed, should excite 
suspicions of syphilis as the cause, enlargements which present the same 
general appearance do occur from other causes. Such a case was observed 
by me in the children's class in the Outdoor Department of Bellevue, and 
Dr. Bulkley details another case in his paper. In the case observed by 
me, the inflammation and enlargement seemed to be strumous. Baumler 
says : " Dactylitis syphilitica does not always originate in the bone ; similar 
appearances may be produced through gummous formation in the sheaths 
of the tendons, and in the fibrous structure of the finger ;" and again, " Its 
outward appearance may be produced also by tuberculosis, enchondroma, 
or sarcoma of the bone-marrow." (Art. Syphilis, Ziemssen's Encycl.) 

Mr. J. Hutchinson, of London, has called attention to the fact, that 
hereditary syphilis, having perhaps been manifested by the usual symp- 
toms during infancy, and then becoming latent, may give rise to new 
symptoms after the fourth year. The most noticeable of these symptoms 
is a dwarfing of the permanent incisor teeth, which are rounded and peg- 
like, and their enamel notched at the free ends of the teeth. On account 
of the small size and shape of the teeth, 
there are interspaces between them. This Fig. 13. 

abnormal development is most marked in 
the central incisors of the upper jaw, and in 
certain cases it is limited to them, and it 
never appears in the other incisors unless 
it does also in them. Another symptom, 
which only appears in hereditary syphilis, 
is an interstitial keratitis occurring on both sides, and attended by the 
deposition of fibrin in the substance of the cornea. In a few weeks the 
inflammation declines, but a slight opacity of the cornea remains. The 
cerebral nerves may become affected, usually a single pair — if the audi- 
tory, deafness resulting ; if the optic, dimness of sight. Occasionally there 
are other manifestations of syphilis in this period, as enlargement of spleen 
and liver, and nodes upon the long bones. 




152 SYPHILIS. 

Prognosis. — This depends in great part on the general condition of 
the patient. If there is much emaciation, and the symptoms indicate a 
deeply-seated cachexia, a considerable proportion perish. On the other 
hand, if the general health is not greatly impaired, although the local 
affections are pretty severe, the prognosis with correct treatment is good. 
The younger the infant, when the symptoms of syphilis appear, the more 
unfavorable, as a rule, is the prognosis. 

Treatment Parents who beget syphilitic children ought, from a due 

regard for their offspring, to make use of antisyphilitic remedies, although 
they present in their persons no evidences of syphilitic taint. A good pre- 
scription for the parents is one-sixteenth of a grain of corrosive sublimate 
in the compound tincture of bark, given twice or three times daily for 
several weeks. If the father has had syphilis, both parents should be sub- 
jected to this treatment, and it may be continued, at least on the part of 
the mother, during the first months of her gestation. So small a dose of 
the mercurial does not, in my opinion, materially increase the liability to 
miscarry. There is much more danger of miscarrying from allowing the 
syphilitic taint to remain uncontrolled. Some prefer the use of mercurial 
ointment in the treatment of pregnant women for syphilis, in the belief 
that it is less likely to produce abortion. It is used for this purpose in the 
proportion of one drachm to the ounce. It is equally effectual in the erad- 
ication of the syphilitic taint with the small dose of corrosive sublimate 
recommended above for internal administration ; but it is impossible to 
determine the quantity of mercury which enters the circulation when in- 
unction is employed, and salivation is more likely to occur. 

Syphilis in the infant requires mercurial treatment as in the adult. 
Mercury may be employed internally or by inunction. Some prefer in- 
unction in the treatment of ordinary cases, in the manner recommended 
by Sir Benjamin Brodie. " I have spread," says he, " mercurial ointment, 
made in the proportion of a drachm to an ounce, over a flannel roller, 
and bound it round the child once a day. The child kicks about, and, 
the cuticle being thin, the mercury is absorbed. It does not either gripe 
or purge, nor does it make the gums sore, but it cures the disease. I have 
adopted this practice in a great many cases, with the most signal success." 
Trousseau, on the other hand, discountenances the use of inunction, as 
mercurial ointment applied to the skin produces irritation, and increases 
the suffering and restlessness of the child. He prefers the following solu- 
tion, which is known as Van Swieten's, for internal treatment :-— 

I£. Hydrarg. bichlorid., 1 part; 
Aquae, 900 parts ; 
Spts. rectific, 100 parts. Misce. 
Dose, one or at most two grammes (15.434 to 30.868 grains), in milk, daily. 

In order to avoid the risk of establishing a diarrhoea, and to leave the 
stomach free for the employment of other medicines, as cod-liver oil and 
the iodide of iron, I prefer and commonly prescribe for infants inunction 



TREATMENT. 153 

with the mercurial ointment diluted with eight times its quantity of lard, 
cold cream, or vaseline. It should not, in my opinion, be applied as a 
plaster, but a quantity of the size of a large chestnut should be rubbed 
three times daily upon the neck or breast of an infant of three or four 
months. For children over the age of eight or ten months Van Swieten's 
or one of the following formulas may be employed :— 

$. Hydrarg. cum creta, gr. iij-vj. 
Saccli. alb., £)j. Misce. 
Divid. in chart. No. xii. One powder 3 times daily. 
I£. Hydrarg. chlor. corros., gr. j-ij. 
Syr. sarsae comp., ^ij. 
Aquae, ]§viij. Misce. 
One teaspoonful 3 times daily. 

^. Hyd. chlor. corros., gr. ss. 
Potas. iodid., ^j. 
Ferri et amnion citrat., ^j. 
Syr. simplic., ^vj. Misce. 
Dose, one teaspoonful 3 times daily for a child of 3 to 5 years. 
I£. Hyd. chlor. corros., gr. j. 
Potas. iodid., gij. 
Syrnp. simplic, 
Aquae, aa ( ^ij. Misce. 
Dose, six drops 3 times daily for a child of 3 months. 

Mercury, in whatever way employed, should not be discontinued en- 
tirely till several weeks after the syphilitic symptoms have disappeared ; 
it is proper to continue it for a time, in diminished quantity and fewer 
doses, after the health seems fully restored. 

When the mercurial is omitted, tonics are often required. The prepa- 
rations of cinchona are useful in certain cases, as are also those of iron. 
If the patient remain feeble and pallid, presenting evidences of struma, 
cod-liver oil and syrup of the iodide of iron will be found beneficial con- 
tinued for some weeks or months after the mercurial is discontinued. At- 
tention should always be given to cleanliness and the hygienic manage- 
ment of the child. In some instances direct treatment of the local affec- 
tions is serviceable. To aid in the cure of syphilitic coryza, the following 
ointment should be applied within the nostrils by a nasal sponge three 
times daily : — 

I£. Ung. hydrarg. nitratis, gij. 
Ung, zinci oxidi, ^ij. Misce. 

Condylomata or mucous patches seated upon the cutaneous surface may 
be dusted with calomel. At my clinique, in April, 1871, a child two years 
and ten months old was presented, with a large condylomatous outgrowth 
near the anus. The history of the child showed that in all probability the 
disease had been contracted within a year from syphilitic children in one 
of the public institutions. Within three weeks this affection disappeared 
by dusting upon it calomel once daily, with appropriate internal treatment. 



SECTION II. 
ERUPTIVE FEVERS. 



CHAPTER I. 

MEASLES. 



The disease known in the vernacular as measles has also the names 
rubeola and morbilli. It is a common exanthematic affection, occurring 
at any age, but most frequently in childhood. It affects once the ma- 
jority of mankind. Writers recognize three stages of measles : first, that 
of invasion, which ends with the appearance of the eruption; secondly, 
the eruptive stage ; and thirdly, the stage of decline or desquamation. 

Symptoms — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages, namely, 
cough, fever, anorexia, and thirst. The eyes present a suffused, moderately 
injected, and brilliant appearance, and the buccal and faucial surface is 
injected. The Schneiderian membrane, and that lining the larynx, trachea, 
and bronchial tubes, participate in the increased vascularity, The cough 
at first is dry, and sometimes distinctly croupy. Catarrhal or false croup, 
indeed, is not infrequent in the initial period of measles. The cough is 
attended by little acceleration of respiration, and by little or no pain in 
the respiratory movements. If auscultation is practised at this early stage, 
we observe the vesicular murmur, somewhat harsh in character, and some- 
times sonorous and sibilant rales. A little later, rales of a moist character 
appear. 

The patient, if old enough, commonly complains of headache, and of 
dull pain in the epigastric region or the centre of the sternum, due to the 
bronchitis. With these local symptoms febrile reaction occurs. The tem- 
perature rises to about 102° or 103°, as indicated by the thermometer in 
the axilla. The pulse numbers from 110 to 130 per minute. The fever 
is somewhat greater than in primary tracheo-bronchitis, except when the 
bronchitis extends to the bronchioles, but it is less than in most cases of 
scarlet fever. 

The fever in the premonitory stage of measles after the first day is not 
uniform. It is attended by remissions and exacerbations, the former 
occurring in the first part of the day, the latter in the evening. Some- 



SYMPTOMS. 155 

times two exacerbations occur in the day. The face is flushed and some- 
what swollen, especially during the times of increase in the fever, and the 
child is drowsy or restless. Vomiting, so common a symptom in the com- 
mencement of scarlet fever, occasionally occurs in measles. While in 
scarlet fever this takes place in the first twenty -four hours, in measles it 
occurs with about equal frequency at any period previously to the erup- 
tion. It was present during the first stage, sometimes almost as late as 
the eruptive period, in thirteen, and was absent in twenty-three cases, in 
which I preserved records in reference to this symptom. 

The duration of the first stage varies in different cases. It is usually 
from two to five days, with an average of about four. Occasionally it is 
more protracted on account of some disturbance in the economy, either 
from exposure to cold or other cause, which prevents the necessary afflux 
of blood towards the surface, and retards the eruption. In eighteen cases 
in my practice in which the duration of the cough previously to the 
appearance of the rash was accurately ascertained, the time varied from 
one to five days, with an average of three and one-third; in ten other cases 
it had continued, the parents stated, about a week, and in five, from one 
to two weeks, previously to the eruption. 

The eruption commences, when the disease pursues its normal course, 
upon the forehead and neck, then the face, and gradually extends down- 
wards, occupying from twemty-four to thirty-six hours in passing over the 
trunk and limbs. It appears first as indistinct red points, not more than 
a line in diameter, which increase in size and become more distinct. Their 
borders are uneven or irregular, or they are finely notched; their general 
shape is, however, circular, except as two or more unite, when they may 
assume any form. The crescentic form which writers describe is due to 
the union of two points of eruption. The largest of these spots, when 
there is no coalescence, do not exceed a quarter of an inch in diameter, 
and many are much smaller. Frequently in plethoric children, if there 
is much fever, there is continuous redness over several inches of surface. 
The eruption is then confluent. This form is often observed upon parts 
of the surface where the capillary circulation is most active, when it is 
discrete elsewhere. In some of these cases, diagnosis of measles from 
scarlet fever is attended with difficulty. 

The rubeolous eruption is slightly elevated. This is not appreciable to 
the sight, but can be ascertained by passing the finger slowly over the 
skin, when a little roughness is felt at the point of eruption. Sometimes 
the elevation, especially in the commencement of the efflorescence, is not 
appreciable, even to the touch. The eruption is broad and flat, never acu- 
minate, never changing its form to the vesicular or pustular. It disappears 
by pressure, and immediately reappears when the pressure is removed. It 
has been compared in appearance to flea-bites. Small, pointed, papular, 
vesicular, or pustular eruptions are sometimes seen in connection with those 



156 MEASLES. 

of measles, but they are accidental, occurring in other states of system, as 
well as in measles, if there is the same augmented temperature. 

In the commencement of the eruptive period the severity of the consti- 
tutional and local symptoms increases. The pulse and temperature cor- 
respond with the character which they presented during the exacerbations 
of the first stage. The features are slightly swollen ; the eyes still watery 
and sensitive to light ; the conjunctiva, ocular and palpebral, and the 
mucous membrane of the cavity of the mouth and of the air-passages, 
continue injected. The tongue is covered with a moist thin fur, and its 
papillae are prominent, though less so than in scarlet fever. The cough 
continues frequent, and is seldom attended with much expectoration, in 
uncomplicated cases ; often there is no expectoration whatever. The appe- 
tite is lost, but drinks are readily taken on account of the thirst. Diar- 
rhoea sometimes occurs on the first day of the eruption, but it lasts only a 
few hours, and, if the disease pursue its usual course, abates of itself. 
With the exception of this the bowels are regular, or a little constipated 
during the eruptive period. 

On the second day of the eruption, or sixth of the fever, the symptoms 
begin to abate. The pulse is less accelerated, and the temperature dimin- 
ishes ; the cough is less frequent and is easier, and the flushed and swollen 
appearance of the face declines. By the close of the third or on the fourth 
day the rash has disappeared in the order in which it extended over the 
body. There only remain faint maculae, which in the course of a day or 
two fade completely. 

With the disappearance of the rash the fever nearly or quite ceases, but 
a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is the rube- 
ola nigra of writers. From cases which I have observed, it is my opinion 
that this should not be considered a distinct species in the vast majority 
of cases, but that the dark color is due to internal inflammation, usually 
capillary bronchitis or pneumonia, which prevents full oxygenation of the 
blood. Rarely rubeola nigra is due to the vitiated state of the blood, or 
the malignant nature of the disease. The course of the eruption in this 
form of measles is somewhat different ; it continues longer, fades more 
slowly, and does not disappear so readily on pressure. Traces of it are 
observed a week or more after its first appearance ; it is apt to be fatal. 
Measles may present this form from the beginning, or, commencing as 
vulgaris, it may pass into rubeola nigra. 

Measles may be irregular in form, but aberrations are less frequent than 
in scarlet fever. Writers describe measles without catarrh, and, on the 
other hand, with catarrh but without the rash. But positive diagnosis in 
such cases must be difficult. It is probable that simple catarrh and roseola 
have sometimes been mistaken for the two forms of irregularity mentioned, 
but when a child, in a family of children affected with measles, presents 



COMPLICATIONS. 157 

all the symptoms of that disease, except the catarrh or except the eruption, 
the diagnosis of irregular measles would, as a rule, be correct. 

Occasionally the stage of invasion is very short, or even absent. In 
one case the parents informed me that the catarrhal symptoms began on 
the day when the eruption appeared. Convulsions sometimes occur at 
the commencement of measles, as well as during its progress. A single 
convulsive attack at the commencement of measles is usually not danger- 
ous ; when repeated, it is more serious ; it is also more serious when it 
occurs in the course of measles. In certain cases the eruption appears in 
an irregular and partial manner, occurring, perhaps, at a late period, and 
indistinctly, upon the trunk alone, or upon the trunk and partially upon 
the legs. In many cases of deferred or partial eruption there is internal 
congestion or inflammation of some part, which causes withdrawal of 
blood from the surface, and thus prevents the normal development of the 
rash. 

When the eruption disappears the third stage commences, that of des- 
quamation. It is characterized by a scanty furfuraceous exfoliation of 
the epidermis. The desquamation is seldom as great as in scarlet fever, 
and it occurs most where the eruption has been thickest and the epidermis 
most inflamed. Exfoliation occurs between the fourth and seventh days 
after the commencement of the eruption, the eighth and the eleventh of 
the disease. In some children it does not take place, or is so slight as not 
to be observed. 

With the disappearance of the rash, the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive 
organs return to their normal state, and convalescence is established. The 
cough continues several days after the other symptoms abate, but it is less 
and less frequent, and is not painful. 

Complications. — The complications of this disease are important. 
Much of the success of the physician in the management of measles 
depends on a correct diagnosis and understanding of them. The most 
frequent of these complications are bronchitis and broncho-pneumonia. 
Slight bronchitis is common in measles, but if it increase so as to cause 
embarrassment of respiration, and become a source of danger, it is prop- 
erly a complication. This complication, as well as pneumonia, may occur 
at any period of measles ; but it commences most frequently in the first 
stage. Occurring in the first stage, it may prevent the regular appearance 
of the rash ; if in the second, it often causes retrocession of it. 

When bronchitis becomes really serious, it usually has invaded the 
minute bronchial tubes. This disease, designated capillar bronchitis or 
suffocative catarrh, I have elsewhere described. The clinical history of 
fatal bronchitis, as a complication of measles, is as follows : The respira- 
tion, at first not notably altered, becomes, by degrees, accelerated, and 
the patient more and more fretful. The pulse, instead of becoming less 



158 MEASLES. 

accelerated, as after the first days of simple measles, is daily more rapid, 
and the respiration more frequent and labored. The dyspnoea gradually 
increases, the infra-mammary region is depressed during each inspiration, 
and the subcrepitant rale is heard on both sides of the chest. There is, 
probably, collapse or inflammation of -some of the lobules. Finally the 
prolabia and lingers become livid, and death occurs from apnoea. Capil- 
lary bronchitis is diagnosticated from pneumonitis by the physical signs. 
It is in the young child more dangerous than that disease, unless perchance 
the latter be double. A large majority of those affected under the age of 
three years, die. The anatomical characters of fatal bronchitis occurring 
in connection with measles, I have had an opportunity to inspect. In an 
infant who died with this complication in the Infants' Hospital in the 
spring of 1867, there were evidences of continuous inflammation from the 
epiglottis to the minutest bronchial tubes. 

Pneumonia as a complication does not differ materially from the idio- 
pathic form, except that it is more protracted and fatal. Its form is in 
most cases catarrhal, resulting from an extension of the bronchial inflam- 
mation. 

The next most frequent serious complication of measles is entero-colitis. 
This may commence at any period during the course of the disease. If the 
colon is more especially the seat of inflammation, the evacuations contain 
mucus and blood, unless in young children, in whom the stools, even in 
severe colitis, commonly have a green color. The anatomical character of 
this complication varies in different cases, like the idiopathic form of in- 
flammation. Sometimes there is simple arborescence of the intestinal 
mucous membrane, with tumefaction of its follicles ; in other cases, in ad- 
dition to increased vascularity, the mucous coat is softened and thickened ; 
and in others still, especially if the inflammatory action has been some- 
what protracted, ulceration occurs, for the most part in the site of the soli- 
tary glands. Exceptionally, in fatal cases of measles attended with diar- 
rhoea, no vascularity is observed after death, although the intestine may 
be somewhat thickened and softened. In these cases the diarrhoea may 
have been non-inflammatory or inflammatory, the injection of the vessels 
having disappeared after death. 

Severe and obstinate diarrhoeal affections occurring with measles, usually 
commence as the primary disease is about declining. They then become 
sequelae, ending fatally in many instances several days or perhaps weeks 
after the disappearance of the eruption. Diarrhoeal attacks, occurring in, 
or previously to, the eruptive stage, are, as a rule, mild and easily re- 
lieved. 

In some grave cases, measles have a tendency from the first to affect 
the internal organs more than the surface. There then coexist bronchitis, 
pneumonia, and entero-colitis, with indistinctness of the eruption on the 
skin. Such complications render a fatal result highly probable. 



COMPLICATION'S. 159 

Another very fatal complication and sequel is true croup, commencing 
when rubeola is beginning to decline ; but it is less frequent than pneu- 
monia or entero-colitis. In catarrhal or false croup, which, as has been 
previously stated, is not infrequent at the commencement of measles, the 
cough has a loud, ringing character. In true croup, on the other hand, it 
is hoarse or harsh, and less distinct, on account of the presence of the 
pseudo-membrane in the larynx. True croup, always a grave disease, is 
more serious when it occurs as a complication of measles than in the idio- 
pathic form, not only because the blood is vitiated and the system reduced 
by the primary affection, but because the inflammation of the mucous sur- 
face is in general more extensive, as is also, I believe, the pseudo-mem- 
brane. This membrane in the croup of measles I have seen extend so 
far down the air-passages, that tracheotomy could not have been attended 
by any decided amelioration of symptoms. This complication, though 
always grave, is not, however, necessarily fatal. I have known cases re- 
cover by inhalation of spray, when for days there had been dyspnoea and 
other evidences of a pretty firm pseudo-membrane. True croup causes 
continuation of the fever, which had perhaps begun to abate. 

Diphtheria, when epidemic, also frequently complicates measles. Much 
of the mortality from measles in this city, since the year 1858, was due 
to this cause. In cases observed by myself, diphtheria usually began 
while the fauces were still inflamed, and sometimes before the eruption 
had begun to fade. 

These are the most common complications of measles. There are others 
of less frequent occurrence, among which may be mentioned congestion of 
the brain, with or without serous effusion. Stomatitis, pharyngitis, and 
otitis are occasional complications. Rarely, also, purpura, attended by 
hemorrhages from the different mucous surfaces, occurs in connection with 
measles. This complication is, however, more frequent in certain other 
constitutional diseases, as scarlet fever, and especially variola. 

It is seen that the inflammations which are apt to occur in the course 
of measles are chiefly of the mucous surfaces. In scarlet fever, on the 
other hand, the inflammations are more frequently serous. 

There are other affections, originating in measles, which are rather 
sequelae than complications. Gangrene of the mouth is one which, as 
stated in another part of this book, is more apt to occur after measles than 
any other disease. After a severe epidemic of measles in the Catholic 
Foundling Asylum, in 1874, three cases of gangrenous vulvitis occurred 
in those who had been affected. Ophthalmia commencing in measles often 
persists for weeks or months. It may give rise to granulation of the 
lids, and cases have been reported of violent inflammation of a purulent 
character, producing ulceration of the cornea, and destroying vision. The 
ophthalmia is sometimes very intractable. Inflammation of the Schnei- 
derian membrane, commonly present during measles, sometimes continues 



160 MEASLES. 

as a sequel, extending back as far as the Eustachian tube, where it may 
cause swelling, with impairment of hearing, and forward to the lip, where 
it may produce chronic eczema. 

Anatomical Characters — I have made, or witnessed, according to 
remembrance, some six post-mortem examinations of those who have died 
in, or immediately after, an attack of measles. In all there were lesions 
due to complications. Indeed, death directly from measles is so rare that 
few have had an opportunity of studying the anatomical characters which 
are peculiar to this affection. In those who have died without any obvi- 
ous coexisting disease, and these cases chiefly occur in the malignant form, 
there has been congestion of the internal organs, especially marked in the 
lungs, and sometimes the tissues appeared softened. The blood, also, in 
the malignant form, has a darker hue than natural, and ecchymotic patches 
have been observed upon the mucous surfaces and elsewhere, corresponding 
in character with the petechias under the skin which sometimes occur in 
this form of measles. In cases resulting fatally from bronchitis or pneu- 
monia the bronchial glands are commonly tumefied in the same manner 
as the mesenteric glands are enlarged in enteritis, and the glands of the 
mesocolon in dysentery. 

Nature Rubeola, like the other exanthematic fevers, is due to a 

materies morbi, the exact nature of which is unknown. It is highly con- 
tagious through the air. It has been inoculated by the serum from vesicles 
which sometimes occur in connection with the rubeolous eruption, and also 
by the blood from a patient. Inoculation does not appear to moderate the 
disease, and as measles, when contracted in the ordinary way, is not in 
itself dangerous, but dangerous only from complications, inoculation is 
not performed, except as a matter of scientific interest. The usual mode 
of propagation is through the air. It is communicated both by the breath 
and clothing. By fomites the virus is sometimes conveyed a long distance. 
The question is still undecided whether rubeola does not sometimes occur 
spontaneously. I have met cases, and have heard of others, one in a 
sparsely settled district, in which there w 7 as no evidence of exposure. Yet 
the immunity of certain islands for centuries, till infected through com- 
merce, renders the doctrine of an origin de novo improbable. 

Twelve to fourteen clays elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's depart- 
ment of Charity Hospital, this period was ascertained to be about twelve 
days. In those who have been inoculated, the incubative period is said 
to have been about one week. Rubeola prevails epidemically, like the 
whole class of infectious diseases, and in different epidemics the type 
varies somewhat, as well as the character of the complications. 

Diagnosis. — The diagnosis of measles, previously to the eruption, is 
often difficult. The catarrhal symptoms then predominate, and these are 
such as may occur independently of any constitutional or blood disease. 



TREATMENT. 161 

The first stage, therefore, of measles, is often mistaken for coryza, or mild 
bronchitis. The points of differential diagnosis are the suffused appear- 
ance of the eyes, the greater degree of fever on the first day than would 
be likely to arise from so moderate an amount of local disease, and on 
subsequent days remission and exacerbation of the fever. Measles in the 
first stage has been mistaken for remittent fever. The catarrhal symp- 
toms should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 
those local symptoms referable to the mucous surfaces, which characterize 
measles. 

Variola on the first day of the eruption has sometimes been diagnosti- 
cated as measles. I recollect once being called to an infant with fatal 
confluent smallpox, who was said to have measles. A physician, a few 
days previously, observing the red points in the commencement of the 
eruption, had made this absurd diagnosis, and, predicting a favorable 
result, had not thought it necessary to repeat his visit. In case of doubt, 
it is the part of prudence to defer making a positive diagnosis. A few 
hours suffice to show the distinctive characters of the rubeolous and vario- 
lous eruptions. But the anxiety of friends often necessitates the expres- 
sion of an opinion. The absence of catarrhal symptoms, the earlier 
appearance of the eruption, and its papular feel under the finger in small- 
pox, enable us to discriminate between the two diseases in the commence- 
ment of the eruptive stage. Moreover, the symptoms in the initial periods 
are different, as will be seen in our description of smallpox. 

Prognosis — This is favorable, provided that there is no serious com- 
plication. With internal inflammatory complication, on the other hand, 
the disease becomes much more grave. A large proportion thus affected 
die. The prognosis is also less favorable in feeble children with scanty 
eruption, or an eruption appearing at a late period and irregularly. 
Dyspnoea, persistent and great acceleration of pulse, and coma, indicate 
an unfavorable ending. Convulsions occur much more rarely in the 
course of measles than in scarlet fever, and when they occur after the 
initial period they usually end in coma and death. 

Treatment — Uncomplicated measles require no medicinal treatment 
except to palliate symptoms. The child should be kept in an airy apart- 
ment, at a uniform temperature of about 70°. A temperature so elevated 
as to be uncomfortable to the nurse is injurious to the patient. But while 
the popular idea is erroneous, that he should be kept in a heated atmo- 
sphere, it is correct that currents of air and sudden reduction of tempera- 
ture are dangerous. A violent and fatal attack of croup occurred in my 
practice in a girl of fifteen, in consequence of exposure at an open window 
at the close of the eruptive stage. The diet should be mild, and for the 
11 



162 MEASLES. 

most part liquid. The patient, indeed, refuses solid food, but, on account 
of the thirst, takes liquids more readily. Farinaceous substances, with 
milk, afford sufficient nutriment in ordinary cases. If the previous health 
has been poor and the vital powers reduced, or if there is a complication, 
more sustaining diet is required. Stimulation by wine or brandy is needed 
in these cases. During the two or three weeks succeeding an attack of 
measles, care should be taken to avoid exposure to cold, or changes of 
temperature, since during this period there is great liability to inflamma- 
tions of the mucous surfaces. 

The cough ordinarily requires treatment, inasmuch as the suffering of 
the child and loss of sleep are largely due to this symptom. Demulcent 
drinks, as flaxseed tea, infusion of slippery-elm bark, or solution of gum 
Arabic, are useful, to which, to render them more palatable, lemon-juice 
may be added. A small Dover's powder, or the following mixture given 
occasionally, relieves the severity and diminishes the frequency of the 
cough : — 

R. Tinct. opii camphorat., 
Syr. scillse, 
Syr. ipecac, aa ^ss ; 
Spts. aether, nitr., 5ij« Misce. 
Dose, one teaspoonful to a child of five years, repeated according to circum- 
stances. 

As the chief danger in measles is from inflammation of the respiratory 
organs, local treatment directed to the chest is important. The chest 
should be covered with oil silk, unless in the mildest cases. This in- 
creases the amount of eruption upon the surface underneath, and, I believe, 
tends greatly to prevent complication by bronchitis and pneumonia. If 
the eruption is tardy in its appearance, or indistinct, it is well to produce 
moderate counter-irritation by some gentle irritant underneath, as cam- 
phorated oil, to which one-third part of turpentine is added. 

Affections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary 
diseases, however, require sustaining measures more than primary. In 
bronchial and pulmonary inflammations, which, if they occur early in 
measles, prevent the regular appearance of the eruption, or, if in the 
eruptive stage, cause its disappearance, prompt counter-irritation over the 
chest by sinapisms, or otherwise, is required. Trousseau states that he 
has derived benefit, in these cases, from what he designates urtication. 
This is produced by stroking the chest two or three times daily with the 
nettle (urtica dioicaor urtica urens). This causes a prompt and abundant 
eruption, and with a less amount of suffering than one would suppose. 
The fever abates, and the respiration becomes more natural in proportion 
to the amount of nettlerash. On the second day the effect is less than on 
the first, and after three or four days, says Trousseau, no further irritation 



SCARLET FEVER. 163 

results from the nettle. When counter-irritation is produced, by what- 
ever method, the chest should be covered with a warm and soft poultice, 
as the ground flaxseed ; derivatives to the extremities are useful in such 
cases. In capillary bronchitis and pneumonia stimulating expectorants 
are required, as carbonate of ammonia. The following I employ for a 
child of two to three years. 

R. Tinct. ipecac, comp. 

(Squibb's liq. Dover's pulv.), gtt. viij-xvj. 
Ammo-ii. carbonat., gr. xvj-^ss. 
Syr. bal. tolut., 
Aquae, aa ^j. Misce. 
One teaspoon ful every 2 or 3 hours. 

Quinia to reduce the fever, and digitalis as a heart tonic, are also very 
useful in these inflammations, given alone or alternately with the above. 

The cases of gangrenous vulvitis alluded to above were treated with a 
flaxseed poultice, and iodoform dusted over the surface each day or second 
day, with a satisfactory result. As regards the treatment of other com- 
plications, the appropriate measures are detailed elsewhere. 



CHAPTER II. 

SCARLET FEVER. 

The terms scarlet fever, scarlet rash, and scarlatina are identical. 
They are employed to designate one of the most frequent and fatal of the 
contagious diseases, a disease which may occur at any age, but is most 
common in childhood, an exanthem attended with more or less pharyn- 
gitis. In this city, on account of its great frequency, and its large per- 
centage of fatal cases, it causes more deaths than any other contagious 
malady. Though not more common than measles, it is attended, with 
us, by more than double its mortality. 

There is no disease that presents a greater difference, as regards char- 
acter and severity of symptoms, than scarlet fever, and this has led to the 
recognition of different forms of it. Rilliet and Barthez describe two, the 
normal and abnormal : Meigs two, the mild and grave ; and most other 
writers, three or more. I shall, for convenience, follow Bouchut, who 
makes three varieties, namely, the regular, irregular, and malignant. 

Symptoms. Regular Form. - -Scarlet fever usually begins abruptly. 
It is possible, often, to tell the exact time of its commencement. If there 
are any premonitory symptoms, they are ordinarily slight, so as scarcely 
to attract attention, amounting to little more than dulness, or the appear- 
ance of fatigue. In some the first symptom is chilliness, and occasionally 



164 SCARLET FEVER. 

a distinct chill is experienced. This is the ordinary mode of commence- 
ment in the adult. With or without the chilliness, fever, usually intense, 
arises, accompanied by such symptoms as ordinarily occur in a febrile 
state of system, such as cephalalgia, perhaps delirium, anorexia, thirst. 
The pulse rises to 110, 120, or more, per minute; the skin is hot, face 
flushed, the eyes bright, and the temperature is 102° to 104°. In many, 
there is sudden starting or twitching, with a degree of stupor, showing 
that the cerebro-spinal system is profoundly affected. 

In most cases there occurs within the first twenty-four hours a symptom 
which has considerable diagnostic value, namely, vomiting. In 117 cases 
in which I have recorded its presence or absence, it occurred in 90, usually 
not at the very commencement, but within the first twelve or eighteen 
hours. It commonly occurred before the appearance of the rash, but not 
always. In a few of the cases it is recorded as a symptom of the second 
day. Vomiting at this period is, probably, in most cases, sympathetic, due 
to the irritating effect of the scarlatinous virus on the brain. It is not a 
severe symptom, occurring in most patients but once or twice. Great and 
persistent irritability of stomach indicates a serious form of scarlet fever, 
and is, therefore, prognostic of an unfavorable ending. When this symp- 
tom is absent or slight, or there is merely nausea, I have found the case 
ordinarily mild, so that, as regards the frequency of vomiting, the statis- 
tics of different epidemics vary according to the mildness or gravity of the 
type. The bowels are regular or somewhat constipated in this form of 
scarlet fever, or, if diarrhoea occur, it is slight and transient. 

When the symptoms described above have continued six to eighteen 
hours, the rash appears. It is first observed about the ears, neck, and 
shoulders, in reddish indistinct patches, fading into the normal hue. These 
patches extend and unite, and in the course of a few hours the trunk and 
upper extremities, and finally the legs, are covered. The scarlatinous rash 
bears considerable resemblance to that produced by external heat or the 
redness from a sinapism, but there are numerous minute points of a deeper 
or duskier red than the surface generally. On passing the finger over the 
eruption, no distinct prominences are observed, but a sensation of rough- 
ness is sometimes imparted from engorgement of the cutaneous papillae. 
The rash disappears by pressure, but in robust children, and in favorable 
cases, it immediately returns when the pressure is removed. Slow return 
of the rash is evidence of sluggish circulation, and, when marked, it indi- 
cates the malignant form of the disease. The rash gives rise to- an i telling 
or burning sensation, which adds greatly to the discomfort of the patient. 
The degree of redness is not uniform over the surface, and sometimes, 
especially in mild cases, it is absent in places. 

Early in the disease, even before the cutaneous eruption, the buccal 
and faucial mucous membrane presents a pretty general red appearance, 
and the papillae of the tongue are elevated. Pharyngitis has already com- 



SYMPTOMS. 165 

menced, with more or less stomatitis and tonsillitis. The inflammation 
renders deglutition painful, so that difficulty is often experienced in giving 
the necessary drinks. This state of the buccal and faucial membrane con- 
tinues through the disease. There is sometimes a slight fibrinous exuda- 
tion over the tonsils ; the tongue is covered with a moist fur, and the 
secretion from the follicles of the inflamed surface is increased and muco- 
purulent. The Schneiderian membrane also participates in the inflamma- 
tion, and, as the disease advances, a thin, irritating discharge, containing 
pus-cells, flows from the nostrils. 

The temperature in the first days of scarlet fever is ordinarily from 102° 
to 105°, in grave cases even 105° to 107°. The cutaneous transpiration 
during this period is nearly checked, so that the skin is hot and dry. The 
respiration is moderately accelerated, but not so as to attract attention, 
unless there is a complication ; often there is slight cough from mucus in 
the throat or bronchial tubes. Bronchitis, common in measles, and giving 
rise to prominent symptoms in that disease, is either absent or slight in 
scarlet fever. 

The symptoms pertaining to the digestive system during the initial 
period of scarlet fever have been sufficiently described. The subsequent 
symptoms do not differ materially in regular scarlet fever, except that 
there is no vomiting. The lips are dry and often cracked. The inflam- 
mation of the mouth and throat continues unabated, with anorexia and 
thirst. The urine is high-colored, and in robust children, during the first 
days of scarlet fever, it frequently deposits the urates on cooling. 

The symptoms continue with undiminished intensity for a period of from 
four to six days, when the fever begins to abate, the pungent heat becomes 
less, and the rash fainter. There is a gradual decline of the disease, which, 
in its inception, was so abrupt. In mild, and even pretty severe cases, 
which pursue a regular and favorable course, convalescence commences 
by the close of the first or beginning of the second week. In the second 
week, the rash, becoming less and less distinct, finally disappears, as do 
also the redness and swelling of the buccal and faucial surfaces. The 
engorgement of the papillae of the tongue and that of the tonsils subsides ; 
the appetite returns ; the countenance brightens and becomes natural, and 
the child who, during the height of the fever, scarcely noticed objects, or 
noticed them with indifference, or even repugnance, can be amused as 
before his sickness. 

The period of desquamation succeeds. Exfoliation of the epidermis 
occurs over the whole body. This commences about the face and neck, 
and it occupies several days, during which there is progressive improve- 
ment in the condition of the child. Where the skin is thin, the epidermis, 
as it is detached, presents a furfuraceous appearance ; where it is thick, as 
upon the palms of the hands and soles of the feet, it separates in a layer of 
considerable thickness. 



166 SCARLET FEVER. 

Such is a brief account of scarlet fever, when it pursues its normal 
course, without complication or sequelae. But there is no disease which 
has so many unfavorable complications and sequelae as this. The liability 
to these accidents renders the prognosis in all cases doubtful, and in many 
instances they are the immediate cause of death. They occur both in 
mild and severe cases of scarlet fever. 

The great difference in different cases of scarlet fever, as regards inten- 
sity of symptoms, is well known. It is sometimes so mild, its character- 
istic features so slight, that diagnosis is necessarily uncertain. Examples 
in corroboration of this statement are not infrequent. In the spring of 
1866 I was called to an infant thirteen months old, who had slight pharyn- 
gitis, and an indistinct rash over a part of the surface. In two days the 
eruption had disappeared, and soon after the health was apparently fully 
restored. Diagnosis would have remained doubtful, except for sequelae. 
In another instance, two children passed through the entire course of 
scarlet fever, playing every day in the street. Although the intelligent 
grandmother saw the rash upon them, its nature was not suspected till 
nearly two weeks afterwards, when one was taken with fatal nephritis and 
general anasarca. In cases so mild as these, the heat of surface is not 
greatly increased, nor is the pulse much accelerated. There is no restless- 
ness, nor is the digestive function materially impaired. The rash does not 
have so deep a color, nor is it so continuous over the surface, as in cases 
of ordinary gravity. The patient begins to improve in from two to four 
days, and is soon well. So mild a form of scarlet fever is, however, quite 
exceptional, but there are all gradations, from this mildness to that malig- 
nant form which I shall presently describe. 

There is usually considerable faucial inflammation, even when scarlet 
fever pursues a regular and favorable course. If the pharyngitis is 
intense and protracted, many writers designate the disease scarlatina 
anginosa. There is, in these cases, not only general and pretty severe 
inflammation of the mucous membrane of the fauces, with swelling of 
the tonsils, and submucous infiltration, but also more or less tumefaction 
around the angle of the jaw, due to extension of the inflammation to the 
lymphatic glands, and connective tissue of the neck. In these cases the 
suffering of the patient is greatly increased by the amount of local disease. 
The adenitis and cellulitis, unless slight, do not subside with the disap- 
pearance of the rash, or they subside more slowly. They render the 
febrile movement more protracted. The swelling due to these inflamma- 
tions often continues one or two weeks after the disappearance of the 
rash, or even longer, when it disappears by resolution, or frequently by 
suppuration, the abscess opening externally. 

Irregular Form. — The irregular form of scarlet fever is commonly due 
to some perturbating cause. This cause is often a pre-existing or coexisting 
disease, or, if not actual disease, at least disordered state of system. For 



SYMPTOMS. 167 

example, a little girl, in my practice, had the symptoms of scarlet fever, 
such as febrile movement and inflammation ot the buccal and faucial sur- 
face, nearly a week before the scarlatinous eruption appeared. During 
this period there were symptoms of enteritis, which declined when the 
rash occurred. The abdominal affection was the apparent cause of the 
irregularity in the malady. If scarlet fever occur during an attack of 
entero-colitis, there is frequently no eruption. Most practitioners have 
met cases like the following, which I now recall to mind : In a family 
where scarlet fever was prevailing, a little child, early after the com- 
mencement of symptoms which seemed to be plainly referable to the ex- 
anthematic affection, was seized with vomiting and purging, and the latter 
continued two or perhaps three days, when death occurred. There were 
the symptoms and appearances of severe scarlet fever, but without the 
eruption. In another instance, an infant, in the warm months, having 
protracted entero-colitis, the usual summer epidemic of this city, was ap- 
parently affected with scarlet fever, which was present in the family. 
There were the characteristic symptoms, but the diarrhoea continued, and 
there was no rash. 

In those that are much reduced by any antecedent disease, as phthisis, 
or that have a disease, chronic or acute, which produces a decided afflux 
of blood towards an internal organ, the eruption is commonly tardy in its 
appearance, indistinct, or wholly absent. The diseases which most fre- 
quently render scarlet fever irregular are those of an inflammatory nature. 
Some affections, occurring in connection with scarlet fever, do not change 
its symptoms, but themselves undergo modification. Scarlet fever occur- 
ring in a child having pertussis does not itself undergo any material 
change. The cough, not the fever, is sometimes modified during the co- 
existence of the two. 

Scarlet fever may also be irregular in those that are robust and free 
from any other disease, assuming this form without any appreciable per- 
turbating cause. In 1867 I attended a young lady, whose previous health 
was excellent, and whose brother was sick at the time with scarlet fever. 
This patient had considerable fever, with pretty severe pharyngitis, and, 
though her surface was repeatedly examined, no eruption could be discov- 
ered. Two weeks subsequently she became affected with severe nephritis, 
anasarca, effusion into at least one of the pleural cavities, and probably 
into the pericardium, the case ending fatally. 

Bllliet and Barthez mention the irregular and incomplete character of 
the eruption in second attacks of scarlet fever, which, though uncommon, 
are met from time to time. Scarlet fever occurring a second time some- 
times presents all the features of the regular disease and pursues its nor- 
mal course, but it is much more apt to be incomplete and irregular than 
the first attack. It is more apt to be irregular if the interval between 
the tw r o has been short than if several years have elapsed. 



168 SCARLET FEVER. 

Malignant Form. — This form of scarlet fever is in some epidemics 
common, while in others it is rare. It usually commences with severe 
symptoms, those pertaining to the nervous system predominating, such as 
intense cephalalgia, with delirium. Many pass rapidly into coma and die 
within two or three days. They succumb to the virulence of the scarla- 
tinous poison, while the disease is still in its commencement. The rash in 
malignant scarlet fever is dusky. It disappears by pressure, and returns 
slowly when the pressure is removed. There is, therefore, extreme slug- 
glishness of the capillary circulation. In some there is great restlessness. 
If placed in one position on the bed they soon throw themselves, in a 
half-conscious or unconscious state, into another. They do not speak at 
all, or they mutter like those affected by the graver forms of typhus, call- 
ing the names of playmates, or talking about things which interested them 
when well. There is great elevation of temperature, the thermometer, 
placed in the axilla, rising above 103° to 105°, even to 107°, and the heat 
of surface is pungent, except when the case approaches a fatal termination. 
The pulse from the first is rapid, numbering from 130 to 160 per minute. 
Sometimes there is great heat of head and body, while the limbs are cool. 
This is an unfavorable sign. 

Severe and dangerous nervous symptoms, as convulsions and coma, 
occur chiefly within the first three or four days. After this period the 
danger is mainly from exhaustion. Those who survive the onset of the 
disease, often have, in the course of a few days, severe pharyngitis, with 
inflammation of the lymphatic glands, and connective tissue around the 
angle of the jaw, accompanied by external swelling. The pharyngitis is 
attended by more or less secretion of mucus or muco-pus, which, some- 
times collecting around the entrance of the larynx, causes noisy respira- 
tion, or even, if the system is greatly prostrated, embarrasses respiration 
by entering the larynx. The chief danger, however, from the pharyngitis, 
is due to the exhaustion which it causes. By rendering deglutition diffi- 
cult, it interferes seriously with nutrition. 

Complications Complications may occur in any form of scarlet 

fever, but they are most frequent in malignant or grave cases. The most 
common and serious complication, as regards the nervous system, is clonic 
convulsions. These occasionally occur at the commencement of the dis- 
ease, before the appearance of the rash, and many then recover, but I 
have not seen, nor have I heard, in my intercourse with physicians, of 
any case which recovered when convulsions occurred after the complete 
development of the eruption. On the other hand, some of the physicians 
of this city, of largest experience, inform me that they consider convul- 
sions during the eruptive stage an almost certain precursor of death. 
Convulsive attacks in scarlatina are probably due, in part, to congestion 
of the nervous centres, for we sometimes find, in young children, at the 
time of the seizure, and immediately before it, the anterior fontanelle pro- 



COMPLICATIONS. 169 

minent, and forcibly pulsating. The convulsions uniformly increase the 
congestion, but, as the latter antedates the former, its causative relation 
seems to be established. But the most important element in the causation 
of convulsions in scarlet fever is, probably, the presence in the blood of 
the scarlatinous virus. This, whatever its exact nature, may, in my 
opinion, cause convulsions, with or without the co-operating influence of 
congestion, as urea gives rise to them in cases of uraemia. Convulsions 
occurring at the commencement of scarlet fever are usually single. If 
repeated, they become more serious. Convulsions after the appearance of 
the eruption, either end at once in coma, or they return at short intervals, 
with gradually increasing drowsiness, till coma supervenes. 

The anginose affection in scarlet fever may be so severe, or assume such 
features, as to constitute a complication. It may become more serious 
than the primary disease itself, so as to require the chief treatment. 
Within the last few years diphtheria has so frequently complicated scarlet 
fever, that physicians have learned to make daily examinations of the 
fauces till convalescence is fully established. So common is this compli- 
cation, that scarlet fever has been justly regarded as affording conditions 
which are especially favorable for the development of diphtheria. Diph- 
theria may begin early in scarlet fever, or not till the latter begins to 
decline, when it produces sudden aggravation of symptoms, and renders 
the case, which before was perhaps favorable, one of great gravity. As 
has been stated elsewhere, a pseudo-membranous formation upon the fau- 
cial surface, especially over the tonsils, is not uncommon in severe anginose 
scarlet fever, but is soft or pultaceous, in isolated points or patches, and 
easily detached. On the other hand, in the cases to which I have alluded, 
of diphtheritic complication, the pseudo-membrane is firm and thick, pene- 
trating the mucous membrane so as to produce bleeding when forcibly 
detached, as in primary diphtheria. Besides affecting the fauces, the 
diphtheritic inflammation is very apt to attack the nostrils, causing swell- 
ing and exudation, so as often to embarrass respiration. This complica- 
tion obviously greatly increases the severity of the case. It intensifies 
the febrile movement, and renders it more protracted. It produces or 
increases the adenitis and cellulitis around the angle of the jaw, causing 
within a few days, if unchecked, such tenderness and swelling of these 
parts as to render movements of the jaw and deglutition painful. 

An occasional result of severe pharyngitis in scarlet fever is suppuration, 
or gangrene occurring in the subcutaneous connective tissue of the neck. 
Whether suppuration occur, and an abscess form, or gangrene result, this 
complication is often serious. Suppuration or gangrene indicates an in- 
tense grade of inflammation or a low vitality ; but many with this com- 
plication recover through a protracted convalescence. 

If suppuration is extensive, it may so increase the debility that death 
occurs in consequence. Gangrene is a more serious complication ; unless 



170 SCARLET FEVER. 

slight, it renders a fatal termination highly probable. The connective 
tissue, subcutaneous or intermuscular, is the part which primarily sloughs. 
The skin over the gangrene becomes brown or dark, and separates with the 
slough. In the majority of cases the slough is not large. Exceptionally 
it extends so deeply that, when it separates, the muscles and even vessels 
of the neck are laid bare, and the appearance is revolting. In a case of 
this sort, which I saw a few years since in the practice of another physi- 
cian, the cavity, after the slough had separated, was irregular, and suffi- 
ciently large to admit a hen's egg. It extended a considerable distance 
out of sight under the skin, and finally opened a vessel from which fatal 
hemorrhage occurred. 

Gangrene of the mouth also occurs in rare instances, either as a com- 
plication or sequel. 1 have met it in two cases, one of which recovered. 
In the fatal case it began while the patient was still under treatment for 
the fever, and was first discovered by the loss of two incisors. The one 
that recovered also lost two incisors, and a part of the superior maxillary 
bone. The one that died was scrofulous, but under good hygienic condi- 
tions ; the other lived in a tenement-house, and was ill-cared for. Rilliet and 
Barthez relate three cases of gangrene of the mouth, occurring, however, 
not as a complication, but sequel, of scarlet fever. One of these patients 
had, within eighteen days, varioloid, scarlet fever, and measles ; these 
diseases ending in fatal gangrene of the pharynx and cheek. The second 
child was taken, on the seventeenth day after the commencement of scarlet 
fever, with gangrene of the pharynx, succeeded by that of the cheek, and 
died on the twenty-fourth day. In the third case the gangrene was pre- 
ceded by smallpox as well as scarlatina. Other observers have recorded 
similar cases. 

Another complication, to which allusion has already been made, is 
entero-colitis. This may antedate the scarlet fever. In other cases, 
entero-colitis commences either with the scarlet fever, or during its course. 
Diarrhoea often occurs in connection with the vomiting, in the first hours 
of the fever; and it commonly ceases during the first or second day. 
Occasionally it continues with greater or less severity, when it constitutes 
a serious complication ; it is in these cases due to intestinal inflammation. 
Bronchitis and pneumonia, so common in measles, do not often complicate 
scarlet fever. 

A not infrequent complication is articular rheumatism, occurring when 
the fever begins to decline. Mild cases are more liable to it than those 
having a severe form. Attention is called to it by the complaint of the 
child of pain or tenderness in the affected joints ; or, if he is too young to 
speak, by evidences of pain when the joints are pressed or moved. There 
are usually but little swelling and redness, and there are fewer joints 
affected than in most cases of acute primary rheumatism. In my practice, 
a common seat of scarlatinous rheumatism has been the areolar tissue of 



COMPLICATIONS. 171 

the wrist. The inflammation and infiltration are less than in primary 
acute rheumatism. This complication is not, ordinarily, serious ; nor does 
it, as a rule, materially retard convalescence. A physician of this city, 
however, informs me of two cases in which cardiac inflammation occurred 
in connection with the articular affection, as it so frequently does in idio- 
pathic rheumatism. The urates are not so commonly present in the urine 
in scarlatinous as in ordinary acute rheumatism. 

Serous inflammation, especially that affecting the peritoneum, pleura, 
or pericardium, is a common complication, independently of the rheumatic 
affection. It occurs during the desquamative period, and, continuing 
afterwards, becomes a sequel. Many such cases are fatal. Pericarditis 
may be with difficulty diagnosticated, if it is slight, and attended by only 
a moderate amount of effusion, and it is, doubtless, often the cause of death 
in those who die suddenly and unexpectedly during or soon after an attack 
of scarlet fever. The pleuritis is often suppurative (empyema), usually 
requiring thoracentesis for its cure, but recovery by ulceration is possible. 
Thus in 1865 I attended a little girl in a mild attack of the fever, and 
when the case was about being discharged, severe pleurisy began on the 
right side. The pleural cavity was soon half filled with liquid, and after 
a sickness of two months, this liquid, mainly pus, communicated with a 
bronchial tube, and was expectorated. She immediately recovered. 

In the following case, the records of which are from my note-book, peri- 
cardial and peritoneal inflammation occurred as a complication of scarlet 
fever : — 

Case April 7th, 1860, C , girl, five years and ten months old, had 

measles two years, and whooping-cough one year ago. With the exception 
of a slight cough, she has since remained well, till the present sickness. 
Scarlatina commenced April 4th, and on the oth the eruption appeared. 
Symptoms severe, but regular; pulse 158, full; surface hot, and covered 
with the eruption ; delirium at night ; stomach irritable ; constipation. 
April 8th to 10th, symptoms about the same; no delirium, however; pulse 
varying from 124 to 153 per minute ; a deposit of urates in the urine. 

11th. To-day, for the first, has severe pain in the epigastrium, accom- 
panied by tenderness on pressure, and moderate distension at this point. 
The symptoms otherwise are favorable, though pretty severe ; pulse 1 40 ; 
respiration moderately accelerated, but the rhythm natural ; respiratory 
murmur distinctly heard in all parts of the chest, vesicular in character, 
and without rales. Has taken till to-day mainly diaphoretic mixtures ; 
to-day pulv. ipecac, comp., gr. iij, every three or four hours, is ordered ; a 
flaxseed poultice to be applied to the epigastrium ; diet nutritious, with 
moderate use of stimulants. 

12th. Epigastric pain still severe; great tenderness on pressure ; con- 
siderable distension at this point, and percussion elicits a dull sound ; 
passed a restless night; when asked where she feels pain, she points to the 
throat and epigastric region ; pulse 130 to 140 per minute ; rash fading; 
surface warm ; bowels somewhat relaxed ; urine passed in usual quantity. 
The treatment by Dover's powder and poultices is continued, and a leech 
is to-day applied to the epigastrium. 



172 SCARLET FEVER. 

loth. Pain less severe, but considerable tenderness on pressure; pulse 
about the same as yesterday; has had through her sickness a slight cough. 
She talks rationally, and sits much of the time in bed. 

14th. Continued in the same state as described in yesterday's records, 
till 3 P. M. yesterday, when she became suddenly worse ; her respiration 
was short and gasping ; she spoke, with an effort, in a whisper, but con- 
tinued conscious ; and her pulse was strong. Death occurred at 5 P. M., 
apparently from obstructed respiration. In the last days of her sickness 
there was but little pharyngitis, and little or no external swelling. 

Autopsy twenty-four hours after death Body a little emaciated ; 

heart large for a child of five years; about one ounce of turbid serum in 
the pericardium ; a soft deposit of lymph within the pericardial sac at the 
base of the heart around the origin of the great vessels, an evidence of 
recent circumscribed pericarditis ; from four to eight ounces of transparent 
serum in each pleural cavity ; no fibrin upon or opacity of the pleural sur- 
faces ; mucous membrane of bronchial tubes injected in streaks, and muco- 
pus can be pressed from them; both lungs can be readily inflated, with 
the exception of small portions of both the lower lobes, which are hepa- 
tized, and can be but partially inflated; liver enlarged, presenting a con- 
gested appearance, and extending some four inches below the free border 
of the ribs ; upon its convex surface in the epigastrium, corresponding 
with the seat of the pain, is a white, rough patch of fibrin, about one and 
a half inches in diameter; kidneys congested; stomach and small intes- 
tines apparently healthy; mesenteric glands moderately enlarged; mu- 
cous membrane of transverse and descending colon somewhat injected and 
thickened, showing mild colitis ; no ulceration noticed ; brain not exam- 
ined. 

Microscopic examination was made of the blood, hepatized portions of 
lung, etc., but nothing of special interest in this connection was observed. 

This case is instructive as showing the liability which exists in and 
after scarlet fever to serous inflammations, and the difficulty of diagnosti- 
cating them in certain cases on account of their circumscribed character. 

Sequelae The complications described above may occur as sequelae, 

but there is another pathological state which may be a complication, and 
is a common and serious sequel. I refer to nephritis with albuminuria. 
This occasionally commences in scarlet fever, but usually not till the dis- 
appearance of the rash. There is sometimes, during the course of scarlet 
fever, and even subsequently, slight albuminuria due to simple congestion 
of the kidneys, but the albuminuria to which I allude, and which requires 
treatment, is more serious. Its anatomical character is as follows : Hy- 
peremia, and perceptible increase in volume of the kidneys ; proliferation 
of the renal epithelial cells like that of the epidermis, and a granular 
deposit in them ; the escape of albumen from the engorged capillaries, 
and its appearance in the urine; the formation of hyaline or granular casts, 
or both, in the tubuli uriniferi, these casts often containing epithelial cells; 
the escape of the casts from the kidneys with the urine ; diminution of 
amount of urea excreted, and, therefore, its accumulation in the blood ; 



SEQUELS. 173 

and, finally, rupture of the engorged capillaries of the kidneys, and min- 
gling of the elements of the blood with the urine. 

The presence, therefore, of this renal affection can be readily ascertained 
by examining the urine. The quantity of albumen which this liquid 
contains can be approximately ascertained by adding nitric acid or apply- 
ing heat. If the quantity is small, simple cloudiness is produced; if large, 
the urine becomes thick and white, and in extreme cases almost semi-solid 
from coagulation of the albumen. The character of the urine can, how- 
ever, be more accurately ascertained by the microscope than by the tests 
which have been mentioned, since by it we discover the casts, altered 
epithelial cells, and blood-corpuscles. 

Nephritis, with the consequent urasmia, soon gives rise to evident symp- 
toms. Serous effusion takes place in consequence of the altered state of 
the blood, the most common form of which is anasarca, occurring upon 
the face and limbs, and sometimes in the connective tissue of the trunk. 
Often the effusion occurs only in the external connective tissue, and the 
result may then be favorable ; but in other cases it occurs, and in the order 
mentioned as regards frequency, in the lungs (oedema pulmonum), serous 
cavities, and, lastly, in the submucous connective tissue of the larynx 
(oedema glottidis.) Obviously the danger in itself from this escape of 
serum depends on its location, but, whenever and wherever observed, it 
indicates the beginning of an unpleasant sequel, and the urine should be 
carefully examined, in order to ascertain the gravity of the renal disease, 
from the amount of albumen and casts. 

Scarlatinous nephritis, with consequent uraemia, is due to the direct 
effect of the scarlatinous poison on the kidneys. I have known it occur 
in the nurse who attended a child through the fever, but did not suffer 
from the fever herself. It sometimes begins quite abruptly, and often 
when the patient has been progressively convalescing, and, perhaps, has 
seemed out of danger. In most cases, however, there are well-marked 
premonitory symptoms, as fever, restlessness, and loss of appetite. The 
anasarca is first observed in the face or about the ankles. Sometimes it 
remains inconsiderable, but in other cases it increases day by day, more 
or less rapidly, till the appearance of the patient is much altered. In 
marked cases of anasarca the features are so bloated that their natural 
expression is lost. The volume of the trunk and legs is augmented, and 
more slowly, that of the arms. In the male child the penis and scrotum 
frequently attain three or four times their normal dimensions, in conse- 
quence of serous infiltration. 

The duration of the anasarca or dropsy is very different in different 
cases. If the form be oedema pulmonum, oedema glottidis, or intracranial 
effusion, death is speedy. It may occur even within a day. Hydrothorax 
and hydropericardium are also ordinarily fatal, though not so speedily ; 
while in ascites the prognosis is much more favorable. The duration of 



174 SCARLET FEVER. 

anasarca under the most favorable circumstances, unless it is very slight, 
is commonly not less than two or three weeks, and is often much longer. 
But the chief danger in a majority of these cases proceeds not from the 
dropsies, but from the poisonous effect of the retained urea on the nervous 
centres, so that in grave cases, nervous symptoms are common, as in 
Bright's disease of the adult. Headache, convulsions, and coma are apt 
to succeed the scanty flow of urine, and ursemic vomiting in fatal cases, 
even when the amount of serous effusion is moderate. 

The liability to this renal malady is greatly increased, and in some 
cases is mainly attributable to the close relationship, as regards their func- 
tions, which exists between the skin and kidneys. A common exciting 
cause is exposure to vicissitudes of temperature or currents of air, by which 
the surface is chilled, and cutaneous transpiration checked, at the time 
when the old epidermis is being detached. The increased burden thrown 
upon the kidneys results in the pathological state which has been described. 
This remark does not conflict with the statement already made, that the 
nephritis is due to the direct effect of the scarlatinous principle on the 
kidneys, the disturbance of the function of the skin merely increasing the 
functional activity of these organs and rendering them more susceptible to 
the disease. All who have seen much of scarlet fever can recall to mind 
cases in which the patients had nearly recovered, when from some needless 
exposure in the streets, or by chilling of the body in a cold room, or open 
window, this affection occurred, with perhaps a fatal result. Elsewhere I 
have alluded to a case in which scarlet fever was only detected by this 
sequel, which began when the child was daily exposed in the open air. 
But many children who have been attended with the utmost care, and 
who, through the whole desquamative period, are kept in a uniform tem- 
perature, nevertheless become affected with albuminuria and dropsy, so 
that there is sufficient cause of this sequel in the state of the child and the 
nature of the disease through which he has passed, apart from extraneous 
influences. It is an interesting fact that albuminuria seems more apt to 
occur after mild than severe cases of scarlet fever, and observations appear 
to show that this difference in liability to nephritis is intrinsic; in other 
words, that it does not depend, as some have supposed, on a difference in 
the hygienic management of mild and severe scarlatina. 

The symptoms in scarlatinous nephritis vary not only according to the 
degree of the inflammation, but also according to the amount and seat of 
the effusion. I have stated that it usually commences with languor and 
more or less fever. The pulse remains accelerated, the skin is hot and 
dry, and the appetite poor. This affection, if slight, may occur without 
appreciable effusion, either in the connective tissue or the cavities, but 
ordinarily in these mild cases a little puffiness is observed around the eyes 
or upon the extremities. In the majority of cases more extensive anasarca 
results. The skin is then pallid, distended, and pitting on pressure. The 



SEQUELS. . 175 

anasarca does not, in most instances, give rise to any marked symptoms. 
If oedema glottidis or pulmonum occur, the respiration becomes rapidly 
more embarrassed, till soon the blood is no longer sufficiently oxygenated 
for the purposes of life. The chief symptom in hydrothorax is accelerated 
and difficult respiration ; in hydropericardium the symptoms are such as 
arise from embarrassed action of the heart ; in ascites there are either no 
marked symptoms, or, if the amount of liquid is large, there may be more 
or less embarrassment of respiration from compression of the lungs. 

Otitis. — Too little attention has unquestionably been given to the state 
of the ear in scarlet fever, and yet the middle ear, lined like the nostrils 
and fauces by a mucous membrane, and in direct continuity with the 
fauces, through the Eustachian tube, is often the seat of an inflammation 
which, if neglected, involves serious ulterior consequences. This inflam- 
mation commonly commences, or becomes so pronounced as to cause symp- 
toms, in the declining stage of scarlet fever, or during convalescence. The 
history of the patient is somewhat as follows : The scarlet fever has pro- 
bably pursued a normal course ; the naso-pharyngeal surface has been for 
some days inflamed, and the redness may be declining, when the child 
begins to complain of earache. The delicate mucous membrane lining the 
Eustachian tube and middle ear is injected and swollen, and the tube be- 
comes impervious by the swelling, so that the tympanum is no longer an 
open, but a closed cavity. The serum, mucus, and pus produced from the 
inflamed tympanic surface, therefore, unable to flow away, collect, and by 
their presence and pressure cause the severe throbbing and aching which 
attend this disease. The effusion, at first largely serous, becomes more 
and more purulent, and, as the quantity increases, the drum is pressed 
outward, the mastoid cells become filled and tender to the touch, and often 
the collateral oedema causes tumefaction and narrowing of the external ear. 
After a variable time, perhaps two or three days, or not till after a week 
of suffering, the drum becomes thinner at one point from ulceration and 
bursts, and the imprisoned secretions escape into the external ear. If this 
terminated the history, it were well ; but, unfortunately, while in a certain 
proportion of cases the aperture in the drum heals kindly, and the inflam- 
mation abates without impairment of hearing or permanent injury of the 
auditory apparatus, there is in a large proportion of cases a subsequent 
unpleasant history. The mucous membrane which lines the bony walls of 
the middle ear has the function of a periosteum, and, therefore, when 
intensely inflamed, and subject to pressure, is liable to ulcerate. As in 
other parts of the skeleton under similar conditions, superficial caries or 
necrosis of the underlying bone is apt to occur. The delicate chain of 
small bones stretching backward from the drum may be irreparably 
damaged, the aperture in the drum may be so large that it never heals, 
and the ossicles, becoming detached, may be lost in the discharge. Cases 
are not rare in which one ear has received this extent of injury, but fortu- 



176 SCARLET FEVER. 

nately the hearing is seldom totally destroyed in both ears. I now recol- 
lect only one such case, although I have met many whose hearing, was 
greatly impaired on both sides, indeed nearly lost. The carious or ne- 
crotic process may extend to the mastoid cells. An offensive otorrhoea 
continuing for months or years indicates the persistence of the inflamma- 
tory process within the ear, which is often rendered so obstinate by the 
presence of dead bone. 

But a more melancholy result is yet in store for certain cases. The 
tympanum is, in a certain part of its extent, separated from the meninges 
of the brain by only a thin layer of bone. The otorrhoea, after months or 
years, suddenly ceases, the child complains of constant severe headache, 
and is feverish, and in a few days death closes the scene in convulsions or 
coma. Fatal meningitis has supervened, produced by extension of inflam- 
mation from the bony wall of the tympanum. Strumous children are 
more liable than others to these serious sequehe of scarlet fever, which 
originate in or proceed from the internal ear. 

Anatomical Characters There is some difficulty in determining 

what are the anatomical characters of scarlet fever, since so many who 
die of this disease have a complication, and the lesions of this are super- 
added to those of the fever. The following, however, are the facts which 
have been ascertained in reference to this point. In many the brain, its 
membranes, and the lungs are congested ; often, also, the Peyerian, soli- 
tary, and mesenteric glands are enlarged, and the spleen enlarged and 
softened. The liver and kidneys do not present any notable alteration, 
though the latter are so often affected during the period of convalescence. 
Dr. Samuel Fenwick (London Lancet, July 23d, 1864) has made post- 
mortem examinations in sixteen cases of scarlet fever, and concludes from 
them that there is inflammation of the mucous membrane of the stomach 
and intestines like that of the skin, and that there is desquamation of the 
epithelial cells from those portions of the digestive tube like that of the 
epidermis. I have had opportunity of examining the stomach and intes- 
tines in a few instances in those who died in the eruptive stage, in the 
Nursery and Child's Hospital, and did not find any ususual hyperemia 
of the gastro-intestinal surface, unless when gastro-intestinal inflammation 
had occurred as a complication. In malignant cases, in which the cardiac 
systole is feeble in the last hours of life, ante-mortem coagulation of fibrin 
frequently occurs in the cavities of the heart, obstructing the circulation, 
and being the immediate cause of death. These clots are large and whitish, 
or yellowish-white. 

Nature — Scarlet fever presents in a marked degree the distinguish- 
ing features of the infectious maladies. It is highly contagious, and is 
inoculable. Stoll, d'Amboise, and others successfully inoculated with the 
scarlatinous virus, using the blood, but without diminishing the intensity 
of the disease. Whether scarlatina ever originates spontaneously is un- 



NATUEE. 177 

certain; but if it do so, such cases are rare. It is disseminated by exposure 
to patients or to fomites, but the distance to which it is contagious is 
short, probably not more than two or three yards. Some consider the 
distance to be even less than one yard. Knowledge of this fact is impor- 
tant, as by isolating in a family a child attacked by scarlet fever, and 
allowing no communication with the nurse, the other children often es- 
cape. A very common mode of communication is by clothing, so that a 
third person is the medium of transmission. I have noticed that when 
scarlet fever, as well as measles, is epidemic in this city, a large propor- 
tion of the cases, nearly all, indeed, of the first cases, can be traced to the 
public schools. Exposure occurs through those children who come from 
apartments where cases are under treatment. Physicians, and especially 
nurses, are sometimes the medium of communication. A medical friend 
of mine went directly from some children with scarlet fever, whom he was 
attending, to another family, where he took a little girl upon his knee. 
This girl in a few days became affected with scarlet fever and died. The 
two remaining children in the family were then attacked, and one died. 
ATurchison alludes to similar cases (London Lancet, August 13, 1864). 
In one instance in my practice scarlet fever was communicated to an 
infant by a washerwoman whose own child had the disease, and who, on 
reaching the house where she had been engaged to work, threw her shawl 
over the cradle where the infant was sleeping. Six days later the infant 
was attacked. Mason Good cites a case in which a box of toys was the 
medium of communication; and it is said that even a letter has been. 
The scarlatinous virus may remain for weeks and even months in apart- 
ments, clothing, or in or upon the person of one who has been affected, 
without any appreciable diminution in its effectiveness. A physician of 
this city, in whose family scarlet fever occurred, excluded a child from 
the room occupied by the patients, and from the patients themselves, for 
a month after the last case occurred, and yet, although precautions had 
been taken in reference to clothes and bedding, this child was taken with 
scarlet fever soon after it was allowed to mingle with the other children.. 
The father believes that the exposure was through the otorrhoea of one of" 
the children. Observations, indeed, appear fully to establish the fact that 
the discharge from the ear or nostrils, and the particles of epidermis 
which have exfoliated, may retain the virus and be the medium of com- 
municating the malady several weeks after the fever has terminated. In 
a case in my practice a little girl returned home six weeks after her 
brother had scarlet fever, and, within a few days, took the disease. A 
more striking example occurred in the practice of Dr. Kearney Eogers,. 
formerly a prominent and much-esteemed surgeon of this city, and was re- 
lated to me by an intelligent friend of the family since the doctor's death. 
Six children in a family had scarlet fever. Three and a half months sub- 
sequently another child, living at a distance, was allowed to visit them in. 
12 



178 SCAELET FEVER. 

the apartments where they had been sick. One week from that day this 
child also sickened with the same malady. Dr. Elliotson states that a pa- 
tient with scarlet fever was admitted into one of the wards of St. Thomas's 
Hospital, and, for two years subsequently, young persons who were 
admitted into this ward were apt to take the disease. Dr. Richardson 
relates the case of a family of four children, residing in the country. One 
died of malignant scarlet fever, and the rest, who had been removed, es- 
caped. Some weeks subsequently one of the children returned, but within 
twenty-four hours took scarlet fever and died. The cottage was now tho- 
roughly cleaned, whitewashed, and the clothing destroyed. Four months 
then elapsed, when the third child returned home, who also took scarlet 
fever in a malignant form and died. It was believed that the virus re- 
mained attached to the thatch, which extended close to the children's bed. 
Other similar examples might be mentioned, sufficient to establish the 
fact of the great permanence of the scarlatinous virus. 

The period of incubation in scarlet fever varies. It is seen in the re- 
markable example of contagion, given above, that it was only twenty -four 
hours. Trousseau also relates an interesting example of short incubation. 
"An English gentleman with his daughter was returning from Pau to 
London, and was joined at Paris by another daughter, who came direct 
from London. Scarlet fever was prevalent in London, but there was not 
a case of it at Pau. The second daughter was seized with scarlet fever in 
crossing the Channel, and joined her relatives in Paris seven or eight hours 
later. She occupied the same room in the hotel as her sister, who was also 
attacked within twenty-four hours." The incubative period is, however, 
seldom so short. It is usually from three to eight days. I might cite 
several cases in which this was its duration. Some writers allude to cases 
in which two, three, or even four weeks elapsed from the time of exposure 
to the appearance of the disease. It is, however, a question whether in 
such cases there may not have been a second and more recent exposure. 
Rostan alludes to cases in which scarlet fever was communicated by inocu- 
lation, and in which the period of incubation was seven days. 

Scarlet fever occurs most frequently between the ages of three and ten 
years. It is infrequent under the age of one year, and infants under the 
age of three months may be considered safe from an attack of it, though 
fully exposed. Cases have been reported of scarlet fever occurring in the 
foetus, and manifesting itself by the usual signs at birth. But a clear 
diagnosis in such instances is necessarily difficult, on account of the cha- 
racter of the scarlatinous eruption on the one hand, and the nature of the 
cutaneous circulation in the newly born on the other. It is probable that, 
in the cases alluded to, there was an error of diagnosis. Certainly in two 
instances I have known women immediately after their confinement 
(within a week) take scarlet fever, and although they communicated the 
disease to others, did not to their infants. Murchison states that twice he 



DIAGNOSIS. 179 

has known women with scarlet fever to be confined, and in both instances 
the infants were healthy. 

Most adults possess immunity from scarlet fever, although not ptotected 
by an attack of it in childhood. Parturient women, however, are liable to 
it. and there is considerable danger that the physicians who attend them, 
if at the same time visiting cases of scarlet fever, may communicate it to 
them. 

Scarlet fever is sometimes sporadic, but, as we meet it in this country, 
it occurs most frequently as an epidemic. The epidemics vary greatly in 
type. Some are mild, and attended by few complications, so that the re- 
sult of treatment is eminently satisfactory. In other epidemics the type is 
malignant, the complications frequent, and the percentage of deaths large. 
There is sometimes a succession of epidemics of one type, and then the 
character of the disease changes. This fact of a variable type is important 
as regards the value of statistics relating to treatment. Each epidemic has 
its prevailing character, but when the form is mild, there is now and then 
a case of severity, and when it is malignant, now and then one of unusual 
mildness. The epidemic influence is sometimes manifested in those ex- 
posed to scarlet fever by the occurrence of pharyngitis, and, as we have 
seen, nephritis. Professor George B. Wood, of Philadelphia, says ( Treatise 
on the Practice of Med.) : " I seldom attend cases of scarlet fever without 
having sore throat." 

Scarlatina usually occurs but once in the same individual, but a second 
attack after the lapse of several years is not uncommon, and there are even 
cases of a third attack, one of which I have witnessed. But physicians 
sometimes mistake roseola or erythema for scarlet fever, and, though after- 
wards aware of their mistake, do not correct their diagnosis. Hence there 
is a belief in community that second attacks are more frequent than 
they really are. 

Diagnosis In the commencement of scarlet fever, prior to the erup- 
tion, there are no symptoms or appearances which will enable us to make 
a positive diagnosis. Positive statement in reference to the nature of the 
disease might better be deferred, for the credit of the physician. Still, if 
a child with regular bowels, and no appreciable local disease, a few days 
after exposure to scarlet fever, is suddenly seized with intense fever, the 
pulse rising to 110, 120, or more, and the temperature to 102°, 103°, or 
105°, there is little doubt that the disease is scarlet fever. The diagnosis 
is rendered more certain if there is vomiting, and especially if, as is usual, 
there is redness of the fauces at this early period, 

TYTien the eruption has appeared, the nature of the malady is, in most 
cases, apparent. Still, roseola or erythema, due to intestinal derangement 
or other causes, has often, as already stated, been mistaken for scarlet 
fever. A day or two suffices to show the error. In scarlet fever there is 
more inflammation of the faucial and buccal surface, more continuous and 



180 SCAELET FEVER. 

persistent redness of the skin, and greater intensity and persistence of 
symptoms, than in those diseases. Scarlet fever is also further distin- 
guished from them by the papular elevations upon the tongue, and the 
minute papulae upon the skin. Besides, in scarlet fever, except in the 
mildest cases, there is from the first the aspect of serious sickness, which 
roseola and erythema do not present. 

Scarlet fever and measles were long considered identical by the profes- 
sion, and, though the ordinary forms of the two diseases can be readily 
distinguished from each other, there are instances in which the differential 
diagnosis is attended by some difficulty. Measles occurring in a robust 
child, with an active cutaneous circulation, sometimes presents a continuous 
eruption over a considerable part of the surface, like the eruption of scar- 
let fever. But the longer period of invasion, the coryza and bronchitis, 
and the absence or slight degree of pharyngitis, in connection with other 
symptoms, enable us to distinguish these cases from scarlatina. Moreover, 
in those cases of measles in which there is continuous redness of surface 
where the circulation is most active, as upon the face, the characteristic 
rubeolous eruption is present in other parts, so that, with care in examina- 
tion, error of diagnosis may be avoided. Scarlet fever and measles may 
indeed occur together, but such a complication is rare. 

The greatest difficulty of diagnosis occurs in abnormal scarlatina, espe- 
cially when the rash is partial and indistinct. There is apt to be, in this 
form of the disease, an inflammatory complication, which causes with- 
drawal of blood from the surface, and it is sometimes very puzzling to de- 
cide whether this is a complication, or the sole disease. The points in- 
volved in diagnosis are numerous, but they are sometimes not sufficient to 
show the character of the affection. Generally, however, by observing 
the clinical history from day to day, the diagnosis is established. In cases 
of doubt it is safest to adopt such hygienic management as is appropriate 
to scarlet fever. 

Prognosis The prognosis depends on the form of the disease, whether 

mild or severe, the presence or absence of complications, and the strength 
of the patient. The mortality varies greatly in different epidemics, in 
those of a mild form, not being more than one in twelve or twenty, and 
the ratio may be less ; while, in those of a severe form, not more than one 
recovers in every two, three, or four. The hospital statistics of Rilliet 
and Barthez show forty-six deaths in eighty-seven cases, while in some 
of the mild epidemics in the New York institutions the mortality has not 
been more than one or two per cent. Scarlet fever, like measles, is liable 
to sudden changes, either from complications which may arise or other 
causes, so that a case which gives a favorable promise in its commence- 
ment may, in a few days, present alarming symptoms. While, in measles, 
death nearly always occurs from a complication, in scarlet fever not a few 
perish from the direct toxic effect of the scarlatinous poison, and not a few 
also from complications or sequelae. 



TREATMENT. 181 

If the symptoms are mild, the temperature not exceeding 104°, with 
little or no delirium or drowsiness, and the efflorescence full, and appear- 
ing at the usual time, we may confidently predict recovery. Nevertheless, 
nephritis, which is one of the gravest sequela?, is so apt to occur after the 
mildest cases, that families should always be warned of the danger, that 
they may avoid needless exposure at the time of the decline of the fever 
and during desquamation. 

The symptoms which indicate an unfavorable ending are convulsions, 
except at the very commencement, great drowsiness with jactitation, a 
temperature exceeding 104° and especially 105°, rapid pulse, duskiness 
of the eruptions, feeble capillary circulation, persistent vomiting, and 
diarrhoea. At a later period, particularly at the close of the first or in 
the second week, other unfavorable symptoms may occur in severe cases. 
The inflammation of the fauces is often so violent that it extends to the 
neighboring glands and connective tissue, producing severe adenitis and 
cellulitis. These inflammations, in proportion to their severity, increase 
and protract the fever, interfere with the proper use of nutriment, and, as 
they are apt to end in suppuration and sometimes in sloughing, they retard 
convalescence, and render recovery more doubtful. 

As dangerous complications and sequela?, such as have been enumerated 
above, are liable to occur suddenly and unexpectedly in mild as well as 
severe cases, it is unwise to make an unconditional favorable prognosis till 
the patient is well advanced in convalescence. Safety is not insured till 
two or three weeks after the eruption. 

Some patients, who have passed through scarlet fever, die of asthenia, 
in consequence of the anaemic state which the fever has produced. They 
have not sufficient vigor to recover, although no serious complication or 
sequel has occurred. Death in the desquamative stage or subsequently 
is more frequently due to the renal affection than to any other cause. The 
nephritis gives rise to dropsies, which are fatal, or to uraemic convulsions 
and coma. Sudden and unexpected deaths are not uncommon in scarlet 
fever, and although they may, sometimes, occur from uraemia, their usual 
immediate cause, as others and myself have had the opportunity to observe 
in the cadaver, is the formation of ante-mortem heart-clots. 

Treatment — It should be borne in mind that scarlet fever cannot be 
shortened or aborted, and that the indications are to sustain the strength, 
reduce excessive fever, and prevent complications. There is no known 
remedy which destroys the poison, when once it has obtained lodgment in 
the system, and begun to produce its characteristic symptoms. Those 
agents, as carbolic acid, salicylic acid, etc., which are most highly es- 
teemed, as disinfectants, cannot be safely used in efficient doses to antago- 
nize the poison in the system, since such doses would seriously impair the 
nutrition and molecular action in the tissues. The expectations raised in 
the minds of many, by the employment of salicylic acid, in the treatment 
both of scarlet fever and diphtheria, have been disappointed, and the use 



182 SCAELET FEVER. 

of the sulpho-carbolates has not, I think, been attended by any better 
success. 

The following is the plan of treatment which can be confidently recom- 
mended as appropriate in ordinary cases : The patient should remain in 
the same room till desquamation is accomplished, and he should stay in 
bed till the fever and the eruption have ceased. The temperature of the 
room during the eruptive and febrile stage should be about 60° ; during 
the desquamative stage, when the patient may be allowed to leave the bed 
for some hours, the temperature of the room should be uniformly at 70° 
to 75°, and the air should be constantly pure from sufficient ventilation, 
without exposing the patient to currents. The linen should be changed 
every day or second day. 

The external treatment of scarlet fever by measures designed to ab- 
stract heat is important. A temperature not exceeding 103° is usually 
safe, so as not to require special treatment, but a temperature at or above 
104° rapidly exhausts the strength and involves great danger. The high 
temperature can be reduced without shock or injury to the child by the 
judicious use of cold water externally, and by inunctions. The cold-water 
treatment is not required unless the temperature exceeds 103°, and it is 
urgently required if it exceed 105°. It has been applied in different ways. 
At one time in the N. Y. Foundling Asylum the patients were stripped, 
and placed for a short time in a bath at 80°, but it caused such fright and 
excitement with a portion at least of the cases, that this treatment was 
discontinued. A preferable way of applying this treatment is by Ziemssen's 
bath, in which water is employed at a temperature of 90°, and gradually 
cooled to 77°. In most cases, however, I prefer to reduce the tempera- 
ture by the constant application to the head of cloths wrung out of cold 
water, or of a bladder containing ice, around which are placed two or three 
thicknesses of muslin or one of flannel, which will insure the proper de- 
gree of cold. At the same time the hands and arms should be bathed 
every few minutes with cool water, to which alcohol may be added. 1 

Trousseau employed cold effusions in sthenic cases, which were attended 
by high temperature, and other grave symptoms. He employed them in 
the first stage of the malady, and considered them especially useful when 
nervous symptoms predominated. He placed the patient naked in a bath- 
ing-tub, and directed three or four pailfuls of water to be thrown over him 
in a space of time varying from a quarter of a minute to one minute, after 
which he was returned to the bed, and covered with the bedclothes with- 
out being wiped. Reaction immediately occurred, often with more or less 
perspiration. This treatment was repeated once or twice daily according 

1 Tlie intelligent and observing sister, who for years has had charge of the qua- 
rantine wards of the N. Y. Foundling Asylum, tells me that sponging has uni- 
formly operated better than the bath, the gradual, but continued abstraction of 
heat, better than the quick and great abstraction. 



TREATMENT. 183 

to the gravity of the symptoms. Trousseau, alluding to the affusion, says, 
" I have never administered it without deriving some benefit.'' I am 
sure, however, that the cautious physician, who wishes to avoid measures 
which excite and frighten the patient will prefer Ziemssen's bath or fre- 
quent sponging of the face and arms, with cold applications to the head, 
especially when aided by inunction of the body and extremities now to be 
described. 

Frequent inunction of the surface in scarlet fever has long been in use. 
An unpleasant symptom in severe cases, and one which increases the rest- 
lessness of the patient, is the pungent heat of surface. Frequent inunction 
reduces this, relieving the dryness of the skin, and so increasing the com- 
fort that the patient asks for it. Leaf lard answers for this purpose, and 
being inexpensive, is within the means of the most destitute family. I 
prefer using the butter of cocoa in cake, or the vaseline to each ounce of 
which five or six drops of carbolic acid may be added. Not only does in- 
unction have the local effect which has been described, but it is stated to 
diminish sensibly the rapidity of the pulse, and the general temperature of 
the body. 

Scarlet fever when mild, and without complication, requires little treat- 
ment, but every case, however mild, should be kept quietly in bed. If 
there is restlessness, an occasional dose of bromide of potassium with a 
warm mustard foot-bath will give relief, and this with the inunction would 
suffice for most of those lightly affected. There is, however, in all cases 
more or less pharyngitis, and as mild cases as well as severe may become 
complicated with diphtheria in localities where diphtheria is endemic or 
epidemic, I employ the following mixture even in the mildest cases : — 

fy. Tine, ferri chloridi, 5ij '■> 
Potas. chlorat., 5U ; 
Syr. simplic, §iv. 

Give one teaspoonful every hour or every second hour, to a child of four 
or five years. The mildest cases are not less liable to nephritis than those 
of a severe type, so that during the disease, and in convalescence, they 
require cautious management as regards exposure to currents of air, or 
sudden changes of temperature, for all those agencies which check cuta- 
neous transpiration, may lead to development of nephritis. 

In the average cases, that is, in those in which the temperature is about 
102° or 103°, and there are no dangerous symptoms, I prescribe the 
above potash and iron mixture, to be given as above, except that on each 
fourth or sixth hour I administer quinine, dissolved in the elixir adjuvans, 
or other convenient vehicle, two grains to a child of four or five years. If 
the pharyngitis begins to abate, or is mild, I often prescribe the following 
mixture in place of the iron and potash. In all cases it will be found 
useful during the declining period. 



184 SCARLET FEVER. 

R. Amnion, carbonat., 

Ferri et ammon. citrat., aa gss ; 
Syr. simplic, ^iv. Misce. 
Dose, one to two teaspoonfuls every second or third liour. 

In severe cases, in which the pulse is quick and weak, the temperature 
above 104°, the capillary circulation languid, the stomach irritable, and 
perhaps the bowels loose, while the nervous system is profoundly affected, 
as shown by drowsiness, delirium, or great restlessness, the condition is 
one of great danger, and measures designed to give relief are urgently 
required. As a temperature above 104° and especially above 105° 
rapidly exhausts the system, the antipyretic treatment by water, recom- 
mended above, should be employed, and the anti-pyretic dose of quinine 
prescribed. Aconite and veratrum viride should never be employed in 
these cases, as they are depressing. Digitalis is preferable to them, but 
it is less antipyretic than quinine. Five grains of quinine may be given 
three times daily to one of five years. If the stomach is irritable, and it 
often is in these cases, ten to fifteen grains may be given in a clyster, and 
repeated after twelve hours. While all but the mildest cases require the 
use at regular intervals of alcohol, either in the form of wine whey or 
milk punch, these severe cases, which are designated malignant, require 
alcoholic stimulants in larger and more frequent doses. If the nervous 
system is profoundly affected, so as to produce great restlessness, or other 
symptoms precursory of convulsions, the use of the bromide of potassium 
is indicated. While cool water may be employed externally for its anti- 
pyretic effect, it is proper to aid in allaying the nervous symptoms, by a 
hot mustard foot-bath. If convulsions occur, which are usually attended 
by the disappearance of the eruption, this bath should be employed at 
once, or a general w r arm bath. 

The large antipyretic doses of quinine should in general only be em- 
ployed for two or three days, as its longer use might involve danger from 
its toxic properties. Afterwards the smaller dose should be given. Digi- 
talis will often be found useful, as a heart tonic, when the pulse is rapid 
and weak. One teaspoonful of the infusion, or four or five drops of the 
tincture, may be given every four hours to a child of five years. In these 
grave cases, which are characterized by great elevation of temperature, 
rapid pulse, and prostration, carbonate of ammonia will also be found 
useful, administered in decided doses, between the quinine or digitalis. 
I prescribe it dissolved in water, so that each teaspoonful contains from 
three to five grains, and direct it to be given in milk, Avhich is the best 
vehicle for it. 

If the patient with malignant scarlet fever live till the fifth or sixth 
day, the urgent neuropathic symptoms begin to abate, and the angina then 
commonly demands more attention. The treatment of the throat has of 
late years become very important, since so many cases are nowadays 



TREATMENT. 185 

complicated with diphtheria. For external treatment I prefer the compress 
wrung out of cool water, and applied from ear to ear, during the first three 
or. four days, if the case is severe, and there is much elevation of tempe- 
rature. If the fever be mild, camphorated oil or a light flaxseed poultice 
is preferable. The poultice appears sometimes to give more relief to the 
tenderness than any other application ; in the declining period it is pre- 
ferable for most patients if any application be needed. I do not, however, 
consider external treatment of the neck important, and I limit its use to 
those cases in which the pharyngitis is most pronounced. The treatment 
of the fancial surface is of more importance, and for this I prefer the use 
of the hand atomizer. This should be used every two to four hours, and 
if the instrument be well constructed, as Richardson's hard-rubber, or 
Delano's metallic, and in good condition, six to twelve compressions of 
the bulb are sufficient, if the following mixture be used : — 
R. Acid, carbolic, gtt. xxxij ; 

Potas. clilorat., 3iij '■> 

Grlycerinae, §iij ; 

Aqure, §v. Misce. 

This spray should be employed at least every two hours, if any exuda- 
tion adhere to the inflamed surface. For infants I dilute the mixture 
with an equal quantity of water. 

The muco-purulent discharge from the nostrils in connection with the 
pharyngeal swelling often so impedes respiration, that it proves annoying 
to the patient and increases his suffering. For this, warm water, with 
about one-two-hundredths part of carbolic acid should be injected into the 
nostrils ; or, which I prefer, thrown into the nostrils in the form of spray 
by the atomizer. Richardson's and some others have a cap or point de- 
signed for the nostrils. The atomizer employed for the fauces is very 
effectual in removing the muco-pus, which often renders the respiration 
noisy and embarrassed in severe cases, for it dilutes the secretion and 
provokes a strong cough. 

The abscess along the neck, which often results from severe adenitis 
and cellulitis, should be punctured early, since it is painful, causes protrac- 
tion of the fever, loss of strength, and restlessness, and, as it is apt to be 
diffused, endangers absorption of the elements of pus. 

The renal affection is often more dangerous than the scarlet fever. A 
clear appreciation of its therapeutic indications is important, since by 
judicious treatment many recover whose lives would inevitably be sacri- 
ficed by improper measures. As there is in these cases active hyperemia 
of the kidneys, having an inflammatory character, diuretics which stimu- 
late these organs should not be given, at least till this pathological state 
has, in a measure, abated. As the eliminative functions of the skin and 
of the intestinal mucous surface are to a considerable extent vicarious with 
that of the kidneys, diaphoretic and purgative remedies are required. By 



186 SCARLET FEVER. 

free diaphoresis the ill effect of arrested or diminished renal secretion is, 
for a time, averted. Treatment to produce diaphoresis should vary some- 
what in different cases. It should in most patients be commenced by the 
use of a warm general or foot-bath, and the patient then be covered in 
bed. If free perspiration is not produced, it may be promoted by sur- 
rounding the body, either with hot dry or moist air. Hot dry air may be 
produced by burning alcohol in a thin layer upon a plate under a chair 
upon which the patient sits, while he is surrounded by a blanket, or he 
may be covered in bed, and the hot air introduced under the bedclothes 
by a common small sheet-iron pipe, the further extremity of which resting 
on the floor contains an alcohol lamp. Hot moist air may be produced by 
placing against the patient one or more bottles of hot water, surrounded 
by a wet cloth. The steam arising from this, and enveloping the body 
and limbs, produces a prompt sudorific effect. There is in use in this city, 
in the treatment of these and similar cases requiring diaphoresis, a con- 
venient apparatus for generating steam. It consists of a cylinder pierced 
with holes for the admission of air, and containing a spirit-lamp over 
which is a pan or pail holding a little water. The patient, nearly denuded, 
is placed in a chair, with the apparatus by his side, and is covered with a 
blanket so that the steam surrounds the body. This gives rise to free 
perspiration, which continues after the patient is placed in bed. This 
treatment may be repeated each day, if the patient require it, while dia- 
phoretics and laxatives are given. The diaphoretics which are most 
serviceable in this affection are the acetates of ammonia and potassa, the 
bitartrate and citrate of potassa, and spiritus oetheris nitrosi. These agents 
used singly or variously combined, increase the diaphoretic effect, if used 
in connection with the external measures described above, which are cal- 
culated to produce diaphoresis. If employed with the surface cool, they 
act rather as diuretics than diaphoretics. 

Diuretics, which do not stimulate the kidneys, are proper at an early 
period of the renal malady, and in my opinion digitalis is more useful than 
any other internal remedy. 1 do not hesitate to administer it from the 
first day, often in combination with acetate of potash, which in addition 
to a diaphoretic and diuretic has a laxative action. Digitalis has the con- 
fidence of the profession of New York more than any other medicine, both 
for the nephritis of children and of adults. One teaspoonful of the in- 
fusion should be given every fourth hour to a child of three to five years. 
The following is a good formula for a child of five years in good general 
condition : — 

R. Potas. acetat., ^ss ; 

Infus. digital., ^vj. Misce. 

For the older robust children with scarlatinous uraemia and serous effu- 
sions no medicines afford so much relief in the commencement as cathartics 
of a hydragogue nature. A mixture of jalap and cream of tartar, pulvis 



TREATMENT. 187 

jalapre compositus of the Pharmacopoeia, meets the indication. Even in 
children somewhat reduced medicines of this nature are often required. 
Cathartics are more certain in their effects than either diaphoretics or 
diuretics, and, therefore, they should be given in urgent cases in which it 
is necessary to remove the urea or serum as speedily as possible. An ex- 
cellent prescription in many of these cases, and one from which I have 
obtained a good result, is the following : — 

R. Podophyllin,, gr. j ; 

Sacch. alb., ^j. Misce. 
Divid. in chart. No. viii-xii. 
Dose, one powder, according to circumstances. 

After the use of laxative agents, the kidneys, being less congested on 
account of the diversion that has occurred, often begin to excrete more 
freely. But if the patient be at all anaemic, or enfeebled, and the symp- 
toms are not urgent, cathartic or other depressing remedy is inadmissible. 
Cases like the following, from my note-book, are not infrequent. A little 
boy, pale and scrofulous, began to have anasarca, after scarlet fever, chiefly 
of the scrotum, and accompanied by a moderate degree of ascites. The 
urine, which was passed in nearly the normal quantity, contained albumen. 
This patient gradually and fully recovered, with no treatment except the 
use of an oil-silk jacket over the kidneys and abdomen, to promote dia- 
phoresis, and the use of iron. Such a case actively treated by eliminatives 
would, probably, have proved fatal. Variation in measures is therefore 
demanded, according to the state of the patients, but digitalis, being a 
heart tonic, is very useful in the asthenic as well as sthenic cases. 

It is evident from what has been stated above that the condition of the 
ear should be closely observed in and after scarlet fever. If the patient 
have earache, considerable relief may be obtained in the commencement 
by dropping a few drops of laudanum and sweet oil into the ear, and 
covering the ear by some hot application, either dry or moist, which 
will retain the heat. A favorite popular remedy in the tenement 
houses of New York, is a bag of dry and hot chamomile flowers, bound 
over the ears. Hot water syringed into the ear is also beneficial, and 
sometimes one or two leeches applied close to the ear aid materially in 
checking the inflammation in the first day or two. In most cases, how- 
ever, the otitis continues, and the drum of the ear should be inspected daily. 

Dr. Albert H. Buck, of New York, in a highly instructive paper on 
this subject, read before the International Medical Congress in 1876, 
writes : " This is the time when paracentesis of the membrana tympani 
produces such beneficial effects. In this one slight operation, which in 
itself is neither dangerous nor very painful, lies the power to prevent the 
whole train of disagreeable and dangerous symptoms." Dr. Buck relates 
an instructive example. The age of the patient was three years, and the 
earache had been complained of only about twenty-four hours. " Towards 



188 SCARLET FEVER. 

morning," says he, " I was sent for, as the pain had become constant. 
. . . An examination with the speculum and reflected light, showed 
an oedematous and bulging membrana tympani (posterior half), the neigh- 
boring parts being very red, though as yet but little swollen. In the most 
prominent portion of the membrane I made an incision, scarcely three 
millimetres (one-tenth inch) in length, and involving simply the different 
layers of the membrana tympani. This was almost immediately followed 
by a watery discharge (without the aid of inflation), which ran down over 
the child's cheek. At the end of three or four minutes the child had 
ceased crying, and in less than a quarter of an hour she was fast asleep. 
At first the discharge was very abundant and mainly watery in character, 
but it steadily diminished in quantity, and became thicker, till finally on 
the fourth day it ceased altogether. On the tenth day the most careful 
examination of the ear could not detect any trace of either the inflamma- 
tion or the artificial opening." This simple operation had probably saved 
the ear from ulceration of the drum, long-continued suppurative otitis, and 
perhaps from permanent impairment of hearing. It is evident that the 
operation should be performed early, before the ear is irreparably injured. 1 
But if the otitis have continued unchecked by treatment till the pent-up 
secretions, after days and nights of suffering, have escaped by ulceration 
through the drum, the opportunity for prompt and certain cure is passed. 
Still the patient under these circumstances may quickly recover, or there 
may be the other alternative described above, in which the ear is badly 
damaged, and a chronic inflammation established in the walls of the tym- 
panum, giving rise to an offensive otorrhoea. Under such conditions, the 
same internal treatment is indicated, which we make use of in suppurative 

1 Dr. 0. D. Pomeroy, an experienced and skilful aurist of New York, has kindly 
furnished the following particulars in reference to this operation. " The forehead 
mirror should he worn in order to leave the hands free to operate, using either 
artificial or daylight. A good-sized speculum is introduced into the meatus. Then 
an ordinary broad needle, about one line in diameter, with a shank of about two 
inches, such as oculists use, for puncturing the cornea, should be held between 
the thumb and fingers, lightly pressed, so as not to dull delicate tactile sensibility. 
The part being well under sight, the most bulging portion of the membrane should 
be lightly and quickly punctured, with a very slight amount of force. The poste- 
rior and superior portion of the membrane is most likely to bulge. The chorda 
tympani nerve ordinarily lies too high up to be wounded. The ossicles are avoided 
by selecting a posterior portion of the membrane. After puncture the ear should 
be inflated by an air-bag, whose nozzle is inserted into a nostril, both nostrils 
being closed, so as to force the fluid from the tympanum. The puncture may need 
to be repeated, at intervals of a day or two, provided that the pain and bulging 
return. In my opinion paracentesis may frequently be rendered unnecessary by 
the timely use of one or two leeches applied to the meatus. Leeching employed 
at the right time rarely fails to subdue the pain and inflammation. 

" New York, Dec. 13, 1878." 

"The leech should be applied at the base of the tragus, either internally or 
externally." Mittendorf. 



PROPHYLAXIS. 189 

inflammations of bone in other parts of the system. The internal use of 
cod-liver oil and iodide of iron is indicated, especially in such cases as 
occur in those who seem to have the strumous diathesis, the object being 
to prevent extension of inflammation, and to produce a more healthy state 
of system, which will facilitate the healing process. The following, or 
some equivalent carbolized solution should be syringed from one to three 
times daily into the ear. It should be used warm with an ear syringe : — 

R. Acid, carbolic, 3 SS '■> 
Glycerinse, §ij ; 
Aquas, §iv. Misce. 

\Ye have stated above that during convalescence precautions should be 
taken to prevent the patient's catching cold, so as to diminish the liability 
to the sequela?, which have now been described. He should not be allowed 
to go in the open air in unpropitious weather till a month after the fever. 
An oil-silk protection, worn over the under-clothes for a month or two, 
from the time that the febrile symptoms begin to decline, and covering the 
lumbar region, affords considerable protection to the kidneys. 

Prophylaxis. — Since the period of Jenner's discovery of the prophy- 
lactic power of vaccination, as regards smallpox, the attention of the 
profession has been frequently directed to the prevention of scarlet fever. 
Belladonna has been employed as a prophylactic, and recommended, but 
its use for this purpose has been fruitless, and is now nearly or quite dis- 
continued. The most reliable, and, indeed, the only efficient prophylactic, 
is isolation, and the proper employment of disinfection in the sick-room 
and upon the patient. There can be no doubt that most of the excretions 
of a child sick with this malady contain the scarlatinous virus, as do also 
the cells of the epidermis, which are thrown off during convalescence, and 
minute particles of which are wafted away as motes in the air. By the 
proper application of washes, which contain carbolic acid, to the fauces 
and nostrils, the secretions from these surfaces are to a great extent disin- 
fected. If otorrhcea occur, the ear should be syringed with warm water 
containing carbolic acid in the proportion of one drachm to the pint, and 
this should be continued after convalescence, for cases occur which show 
that the discharge from the ear has probably been the medium by which 
the virus was communicated, even as late as the fourth week after the 
disappearance of the rash. Children in the midst of the fever usually 
experience a degree of relief from inunction of the surfaces, and if carbolic 
acid be added to the substance, which is employed for this purpose, and 
the inunction be made twice daily over the entire surface, contamination 
of the air through the exhalations and exfoliations from the skin is in 
great part prevented. A convalescent child should not be allowed to min- 
gle with other children till three or four weeks have elapsed, and all who 
are liable to take the malady should be excluded from the room in which 
a case has occurred for a longer period. 



190 SCARLET FEVER. 

The New York Health Board enforce the -following excellent regula- 
tions against scarlet fever as Avell as measles : — 

" Care of Patients. — The patient should be placed in a separate room, 
and no person except the physician, nurse, or mother, allowed to enter 
the room, or to touch the bedding or clothing used in the sick-room, until 
they have been thoroughly disinfected. 

" Infected Articles All clothing, bedding, or other articles not abso- 
lutely necessary for the use of the patient, should be removed from the 
sick-room. Articles used about the patient, such as sheets, pillow-cases, 
blankets, or clothes, must not be removed from the sick-room until they 
have been disinfected, by placing them in a tub with the following disin- 
fecting fluid : eight ounces of sulphate of zinc, one ounce of carbolic acid, 
three gallons of water. 

" They should be soaked in this fluid for at least one hour, and then 
placed in boiling water for washing; 

" A piece of muslin, one foot square, should be dipped in the same solu- 
tion and suspended in the sick-room constantly, and the same should be 
done in the hallway adjoining the sick-room. . . . 

" All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately 
after use by the patient be emptied and cleansed with boiling water. 
Water closets and privies should also be disinfected daily with the same 
fluid, or a solution of chloride of iron, one pound to a gallon of water, 
adding one or two ounces of carbolic acid. 

o 

" All straw beds should be burned. . . . 

" It is advised not to use handkerchiefs about the patient, but rather 
soft rags for cleansing the nostrils and mouth, which should be imme- 
diately thereafter burned. 

" The ceilings and side walls of the sick-room after removal of the 
patient should be thoroughly cleaned and lime washed, and the woodwork 
and floor thoroughly scrubbed with soap and water." 

By such measures of prevention there can be no doubt that the number 
of cases of scarlet fever would be greatly reduced. Dr. William Budd, of 
Bristol, England, has for years recommended similar precautions in the 
families which he attends, and the following is his testimony in regard to 
the result: " The success of this method, in my own hands, has been very 
remarkable. For a period of nearly twenty years, during which I have 
employed it in a very wide field, I have never known the disease to spread 
in a single instance beyond the sick-room, and in very few instances 
within it. Time after time I have treated this fever in houses crowded 
from attic to basement with children and others, who have nevertheless 
escaped infection. The two elements in the method are, separation on 
the one hand, and disinfection on the other." (British Medical Journal, 
January 9, 1869.) 



ROTHELX. 191 



CHAPTER III. 

ROTHELN. 

The disease known as rotheln is rare in this country. On the Conti- 
nent, especially in Germany, on the other hand, it has been known many 
years, and German writers describe it under the term rubeola, which we 
apply to ordinary measles. This nomenclature produces confusion in 
terms, and hence rotheln is sometimes designated German measles. 
Meagre and imperfect descriptions of this malady have appeared in some 
of the British journals, and cases quite fully detailed have also been pub- 
lished by British physicians. 

In this country rotheln is not entirely new, though most physicians have 
never seen a case of it. Cases occurring in or about Boston were described 
by Dr. Homans, Sr., in 1845, and at later dates, namely, in 1853 and 1871, 
B. E. Cotting, M.D., Harvard, saw cases, and described them in papers 
read before local societies. (See Boston Med. and Surg. Journal, March 
15, 1873.) In 1874, Dr. Caleb Green, of Homer, Cortland County, 
N. Y., an accurate and intelligent observer, also witnessed an epidemic. 

An epidemic of this rare and interesting malady has recently prevailed 
in New York city, the first, so far as 1 am aM 7 are, in this locality. In 
a general practice of more than twenty years, extending over a consider- 
able portion of this city, I had previously observed nothing like it, and 
other older physicians having a large general practice, have informed me 
that they consider it an entirely new disease with us. Those who think 
that they have occasionally seen isolated cases of it previously to the 
recent epidemic, evidently refer to roseola. 

This epidemic of rotheln commenced in New York, near the close of 
1873, and attained its maximum prevalence in March and April, 1874, 
when it declined, occasional cases occurring throughout May. The first 
case which I observed occurred in the middle of December, in Seventy- 
first Street, being in the suburbs of New York, on the north. A few weeks 
later, cases were so numerous in the thickly settled portions of the city as 
to attract the attention of many physicians. It was evident that a disease 
had appeared with which we were not familiar, and as the eruption oc- 
curred in points, or small circumscribed patches, it was, I think, usually 
designated by the physician, in want of a more accurate name, epidemic 
roseola, or was spoken of as a spurious measles. Those physicians who 
were familiar with foreign medical literature saw the resemblance between 
these cases and those of rotheln as described by British and continental 
observers, but in certain, at least, of the foreign cases the duration of the 



192 ROTHELN. 

rash was said to be seven days (Liveing, Lancet, March 14, 1874, and 
Medical News and Library, May, 1874), whereas in the cases in New 
York it commonly disappeared by the fourth day. But this discrepancy 
was not sufficient to invalidate the belief in the identity of the New York 
disease with the foreign rotheln. It was readily explained by the differ- 
ence in the seasons in which the cases occurred, for Liveing observed his 
cases in June and July, and the greater the external heat the longer the 
duration of the eruption, as we will see. 

Between the middle of December and the 1st of May I had observed 
and treated this malady in eighteen families. Cases occurred in three 
other families living in the same houses with some of those which I attended, 
and as they were fully and clearly described to me, so that there could be 
no doubt as to their nature, I have included them in my statistics. Forty- 
eight cases were observed in the twenty-one families. During May, when 
the epidemic was declining, I saw six additional cases occurring singly in 
families, making a total of fifty -four. 

Age. Cases. 

From 8 months to 1 year ........ 2 

" 1 year to 2 years ........ 4 

" 2 years to 5 " 16 

" 5 " 10 " '. .23 

" 10 15 " 3 

" 15 " 30 " 6 

Total 54 

The age of the youngest patient was eight months, and that of the oldest 
thirty years. Seventy-two per cent, of the cases were between the ages of 
two and ten years, so that rotheln is pre-eminently a disease of childhood. 
Individuals in and beyond the middle period of life seem to have nearly an 
immunity from it. The age of the oldest patient of whom I have been 
informed, was about forty years. On March 25th, when I was on duty in 
the New York Catholic Foundling Asylum, rotheln occurred in a boy aged 
four years, following closely an extensive epidemic of measles among the 
inmates. In April, during the attendance of Drs. O'Dwyer and Reid, 
about thirty children were affected with it in this institution, while among 
the large number of female nurses and employes, who were chiefly between 
the ages of twenty and thirty years, all but three escaped. 

Premonitory Stage. — Premonitory symptoms are in most instances 
either absent, or so mild as to attract little attention. It not unfrequently 
happened in the New York epidemic, that the parents were first made 
aware of the sickness of their children by observing the eruption. In one 
or two instances in my practice, children were sent from school not because 
they felt too ill to remain, but on account of the unusual appearance of 
the skin. Commonly, however, in those old enough to express their sensa- 
tions, a premonitory stage of some hours, or a day, or even of longer dura- 
tion was present, consisting of slight languor with headache, and sometimes 



SYMPTOMS. 193 

nausea. Now and then patients vomited previously to the eruption, as 
they frequently did during the first and second days of the eruptive stage. 
In only one instance did I observe grave prodromic symptoms. A boy, aged 
eight years, was suddenly seized with clonic convulsions, and while he 
was in the hot bath for the relief of these, the rash appeared along his back; 

Symptoms Tegumentary System, (a) Skin. — The eruption may ap- 
pear first upon the back as in the above case. In other instances it is first 
observed upon the chest or neck, and in others still upon the cheek or 
forehead. As in morbilli it travels downward, appearing after some hours 
or a day upon the legs. It occurs upon all parts of the body unless upon 
the scalp and the palmar and plantar surfaces of hands and feet. The 
eruption in a majority of the cases which I have observed, gradually 
faded and disappeared, as already stated, by the fourth day. Children 
who were kept warm in bed, or in warm apartments, had it longer than 
others. In many instances traces of it were still visible when the patients 
Avere heated by exercise or excitement several days after recovery. A 
girl aged thirteen years, presented traces of it at times, though indis- 
tinctly, for three weeks. In most of the cases in the New York epidemic 
the rash commonly occurred in small circular patches, having nearly the 
size as well as color of those in morbilli, interspersed with which were 
numerous smaller eruptions, scarcely more than points of the same color. 
Between these patches and points the skin presented the normal appear- 
ance, unless an occasional gooseflesh contraction. In exceptional instances 
the rash resembled that of scarlet fever, extending continuously over a 
considerable extent of surface. Thus in a boy of three years it presented 
so closely the appearance of the scarlatinous efflorescence over the trunk, 
that were it not that the temperature was constantly below one hundred 
degrees, and within three or four days all febrile movement had ceased, I 
would probably have considered the malady a mild scarlatina. In certain 
patients the eruption, being in circumscribed patches and points, in the 
beginning like that of measles, becomes in two or three days confluent, 
so as to resemble the scarlatinous efflorescence, while over other parts the 
patches remain discrete. This was the character of the eruption upon 
the third and fourth days upon the extremities of a little boy in the 
Foundling Asylum. The rash is attended by considerable itching, disap- 
pears on pressure, produces slight roughness of the surface as ascertained 
by passing the fingers gently over it, and it usually disappears without 
desquamation. Exceptionally there is slight branny exfoliation, and in 
one instance which I observed the exfoliation was as considerable over the 
abdomen as in cases of scarlatina. 

(b) Mucous Membrane In connection with the cutaneous eruption, a 

mild inflammation also occurs of the mucous membrane covering the 
fauces, buccal cavity and nostrils, and of the reflection of this membrane 
over the eyes and eyelids, namely, of the conjunctiva. In certain patients 
13 



194 EOTHELN. 

this inflammation is scarcely appreciable, but in the majority it arrests 
attention at once. It produces more or less soreness of the throat, swell- 
ing of the tonsils, and even of the lymphatic glands in the vicinity of the 
tonsils, sneezing, and sometimes a slight discharge from the nostrils. It 
produces also a suffused, reddish, or weak appearance of the eyes, with a 
moderately increased lachrymation. On inverting the eyelids the palpe- 
bral conjunctiva is seen to be injected. In certain patients a moderate 
puriform secretion collects at the inner angle of the eyelids. The eyelids 
are probably in most cases more or less oedematous, but the swelling is 
usually slight, and is apt to be overlooked by the physician. In three 
cases, which I now recall, mothers have directed my attention to this 
cedema. In one of these, to wit, an infant of twenty-three months, there 
was so great tumefaction of the eyelids, commencing about the time when 
the eruption began to fade, that light was totally excluded from the eyes, 
and it was impossible to ascertain their condition. The skin covering the 
eyelids retained nearly its normal appearance, and the puriform secretion 
alluded to above, appeared between the lids. In three or four days the 
oedema of the lids, and the hyperaemia of the conjunctiva rapidly declined. 
Pulse — Temperature The largest number of accurate daily observa- 
tions relating to the temperature made during the epidemic in this city, were, 
I think, those of Dr. Reid in the Foundling Asylum in East 68th Street 
in March. He has kindly furnished me his statistics relating to this symp- 
tom, as follows: "The number of closely observed cases in which the 
temperature was taken was twenty -four. In seventeen of the cases the 
temperature ranged from 97° to 99°; in six it reached 100°, 100^°, and 
100|° ; in one it reached 103^° on the second day of the eruption, but 
remained so elevated only one day." In certain patients Dr. Reid ob- 
served what he designates "a tendency to the development of an ephe- 
meral fever." These observations correspond closely with those made by 
myself in private practice. Thus in sixteen cases I found the tempera- 
tures taken each day constantly between 98° and 100°, with a pulse under 
110 per minute, except in one case in which it numbered 124. In certain 
other cases there was a more decided febrile movement, lasting from one 
to two or three days, occurring usually in the commencement. Thus a 
girl aged three and a half years had a temperature of 101 1° and a pulse 
of 128. In another case the pulse was 124 and temperature 102°. In 
another, a girl aged three and a half years, there was active febrile move- 
ment on Saturday night, occurring without apparent cause. This abated 
on the following day, and she seemed well till Tuesday, when the febrile 
movement returned, and the eruption appeared. On Thursday the tem- 
perature from 102° to 103° fell to 99 1 - , and within a day or two she was 
convalescent. In two other patients from two to four days after the dis- 
appearance of the eruption, an accession of fever occurred, lasting about 
one day, and attended by complaint of pain or distress in the epigastric 
region, but without vomiting or diarrhoea. In one of these the tempera- 



COMPLICATIONS — NATURE. 195 

ture was 103J° and the pulse was 130 per minute; in the other case tern-, 
perature and pulse did not seem to be below these figures, but they were 
not accurately ascertained. Occasionally in the New York epidemic the 
febrile movement was obviously due more to complications than to the 
primary disease. Thus in two cases which I observed the febrile move- 
ment was mainly attributable to mild diphtheritic inflammation which had 
attacked the fauces. 

The observations therefore of Dr. Reid in the Foundling Asylum and 
my own in private practice, show that the febrile movement is constantly 
mild in most cases of uncomplicated rotheln, but that certain patients 
have temporary exacerbations of fever in which the temperature is as 
elevated as in scarlet fever or severe measles. 

Respiratory System The mucous membrane of the larynx, trachea, 

and bronchial tubes does not participate or participates but slightly in the 
inflammation which involves the nasal, buccal, and faucial surfaces. A 
large proportion of my patients had no cough whatever, but others had 
an occasional slight cough. A few had a cough commencing so long pre- 
viously that it was evidently accidental and not a symptom. 

Digestive System — The tongue in rotheln is moist and of normal appear- 
ance, or covered with a slight fur. The appetite is impaired but not lost, 
there is slight or no thirst and the bowels are regular. Nausea is a com- 
mon symptom both during the premonitory stage and in the period of the 
eruption. Vomiting was present in several cases which I observed as one 
of the first premonitory symptoms ; in certain patients it occurred like- 
wise on the first or second day of the eruption. In other patients there 
was no nausea so far as could be ascertained, either immediately before, 
or during the disease. This symptom is less common in rotheln than in 
scarlet fever, but is as common apparently as in morbilli. Foreign ob- 
servers have occasionally remarked the presence of albumen in the urine 
of patients affected with rotheln. I am not aware that it was observed in 
the New York epidemic, but I think that the urine was seldom examined 
by the appropriate tests. I made the examination in three different cases, 
but found no albumen unless a slight trace in one. 

Complications — Prognosis. — The only complications which occurred 
in my cases were those already alluded to, namely, mild diphtheria in two 
patients. Diphtheria being at the time prevalent, the diphtheritic inflam- 
mation occurred by preference upon those faucial surfaces which were 
already the seat of inflammation. We see the same preference in cases of 
scarlet fever and measles. In the Foundling Asylum varicella compli- 
cated one case and pneumonia another. In a third case pneumonia ap- 
peared three days after the disappearance of the eruption. The prognosis 
in rotheln is very favorable. Patients do not die from the severity or 
depressing effect of the disease, as we observe in cases of scarlet fever, 
and with the exception of diphtheria there does not seem to be in it any 
tendency to the development of complications. 



196 ROTHELN. 

Nature — Is rotheln a malady per se, or is it a malady with which we 
have been familiar under another name, but whose form and character 
are modified by unusual meteorological conditions ? Most of the cases in 
the New York epidemic bore considerable resemblance to cases of measles, 
both as regards the appearance and duration of the eruption, and the 
mucous inflammations. Parents often diagnosticated measles before the 
arrival of the physician, and the physician himself at first glance some- 
times made the same diagnosis. But in rotheln the shortness and mild- 
ness of the premonitory stage, lack of uniformity and certain peculiarities 
of the eruption already pointed out, absence of bronchitis and general 
mildness of symptoms, with uniform favorable prognosis, afford a strong 
contrast with measles. But the decisive proof that rotheln is not a modi- 
fied measles is found in the fact that the one does not prevent the occur- 
rence of the other. Of the forty-eight cases observed by myself prior 
to May 1st, nineteen at least had had measles, and one who had rotheln 
took measles a month subsequently. I have already stated that in the 
Foundling Asylum rotheln closely followed an epidemic of measles. A 
considerable number of the children affected with the former disease had 
recently recovered from the latter. 

That rotheln is not a form of scarlet fever is evident from the fact that, 
as regards at least the New York epidemic, the rash was in most instances 
quite different from the scarlatinous efflorescence, occurring, as we have 
seen, in small more or less circular points and patches. Moreover, there is 
in rotheln a slight febrile movement and general mildness of symptoms 
quite unlike what we observe in scarlatina ; or if there is a considerable 
febrile movement, it has a short duration. But the conclusive proof of an 
essential difference between these two diseases, is found in the fact already 
stated in regard to measles, namely, that an attack of the one malady 
does not prevent the occurrence of the other. There are, it is true, cases 
in which it is difficult to make the differential diagnosis between rotheln 
and mild measles or mild scarlatina at first, but when the course of the 
malady has been closely observed for three or four days, it will rarely 
happen, I think, that we are unable to make out its character. 

The first cases of rotheln observed in the New York epidemic were 
often, as I have stated, designated by the name epidemic roseola by the 
physicians who were called to treat them, since they were ignorant of their 
true nature, and in want of a better name. But rotheln differs so widely 
from the peculiar form of dermatitis known as roseola, that it may be 
properly said to have no kinship with it. The successive occurrence of the 
eruption in rotheln over the upper and then the lower part of the body, 
but covering the whole surface, its definite duration of three to five days, 
its size, usually larger than that of roseola, are points of difference. More- 
over, roseola would not, without so great a change in its character as to 
become virtually a distinct disease, occur in the cool months, without any 
appreciable dietetic cause, as an epidemic over a certain area, and for a 



NATURE. 197 

limited time, affecting whole households of children, and sparing other 
households as well as individuals of a certain age. We, therefore, con- 
clude that rotheln, though presenting certain resemblances to roseola, as 
well as to measles and scarlet fever, is a disease per se. 

The cases of an epidemic malady, which occur when its causes or con- 
ditions are most strongly operative, and which are at this time apt to be 
typical, obviously afford the best data for studying its nature. Such were 
the forty-eight cases which I observed. In thirteen of the twenty-one 
families, the first cases were children who, up to the time of the seizure, 
were attending the public or private schools, and in certain instances those 
who were nearly simultaneously attacked, living perhaps in streets widely 
apart, were attending the same school. We see in this a close resemblance 
to the mode in which those common exanthematic diseases of childhood, 
which are universally admitted to be contagious, as scarlet fever and 
measles, spread in a community. It is largely through the schools that 
these diseases are introduced into families. 

In most of the families containing two or more children, the cases were 
multiple, not occurring simultaneously but in succession, as if the malady 
were contracted from the one first affected. This is what we daily witness 
in the spread of the exanthematic fevers. In the first of the above fami- 
lies, to wit, Mr. E 's, a girl attending one of the public schools takes 

rotheln in the middle of December. The two remaining children sicken 
with it, one week and two weeks later. A niece visiting in the family at 
the time when the first child was sick, but returning home to another street 
soon after, also has the eruption on December 27th. Alice R., aged ten 

years, a frequent visitor at Mr. E 's, living in the same street and several 

times exposed to his children during their sickness, takes rotheln about 
January 4th. West Seventy-first Street, where this family resided, is sub- 
urban and thinly settled, and I could not learn of other cases in that locality. 

These facts and cases seem to me to demonstrate the contagiousness of 
rotheln, at least during the time in which the conditions are most favor- 
able for its development, or during the time in which the epidemic influ- 
ence is most pronounced. During the declining period of the New York 
epidemic, the cases which I observed, as they occurred singly and without 
known exposure, lent no support to the theory of contagiousness. 

From facts and observations like the above, we infer that rotheln is 
one of the exanthematic fevers. It resembles varicella in general mildness 
of symptoms, in the absence of dangerous complications or sequelae, and in 
the uniformly favorable prognosis, while its symptoms and history show 
its close alliance with measles and scarlet fever. If this view is correct, 
we must believe that it possesses an incubative period, which in the cases 
detailed above apparently varied between seven and twenty-one days. 
The incubative period, therefore, resembles that of scarlet fever, which, as 
is well known, is very unequal in different instances. 

Rotheln, like varicella, requires little treatment. I commonly gave 
small doses of quinine to my patients. 



198 VARIOLA. 



CHAPTER IV. 

VARIOLA— VARIOLOID. 

Variola, or smallpox, is a specific febrile affection, accompanied by 
a vesiculo-pustular eruption of the skin. Since the discovery of the pro- 
tective power of vaccination it has been shorn of much of its terror, but 
it is still the most loathsome and most dreaded of all the fevers. Two 
forms of this disease are recognized, depending on the fact whether there 
has been previous vaccination. If the patient has been vaccinated at 
some period in his life, the disease, which is rendered milder in conse- 
quence, is designated varioloid. If there has been no vaccination, it is 
called variola or smallpox. Both forms are identical in nature, the one 
communicating the other ; they differ only in gravity. 

Smallpox presents four stages : the initial, or that of invasion ; the 
eruptive ; that of desiccation ; and, lastly, that of desquamation. It is 
called discrete when the pustules remain separated from each other ; con- 
fluent when they unite. This division is made according to the character 
of the eruption upon the face and hands. There are parts of the surface, 
as the abdomen, where the pustules are always discrete, even in the con- 
fluent form. 

Incubative Period — During the last half of the last century inocu- 
lation with variolous matter was extensively practised in Great Britain 
and on the Continent, as it was found that smallpox thus communicated 
was milder than when received by infection. This operation enabled 
physicians to determine the period of incubation, which was found to be 
from eight to eleven days. When variola is communicated through the 
air, the incubative period is somewhat longer, namely, from twelve to 
fourteen days. 

Stage of Invasion Smallpox begins abruptly with chilliness. In 

children of an advanced age there is often, as in the adult, a distinct 
chill. This is followed by fever and such symptoms as usually accom- 
pany febrile movement, namely, lassitude, anorexia, and thirst. In addi- 
tion certain symptoms arise which, though not peculiar to smallpox, are 
so marked in the commencement of this disease, that they possess con- 
siderable diagnostic value. These symptoms, which pertain to the nervous 
system and occur in the initial stage of varioloid as well as variola, are 
severe frontal headache, pain in the small of the back, and great drowsi- 
ness, sometimes with delirium. In many children convulsions occur, pre- 
ceded and followed by a degree of stupor which is almost as profound 



STAGE OF ERUPTION. 199 

as coma. Trousseau suggests the name rachialgia for the pain in the 
back, as he believes that it is located in or around the spinal cord. This 
belief is based on the fact which he, as well as other observers, has 
noticed, that there is sometimes in connection with this symptom an in- 
complete paraplegia, indicated by numbness of the legs, or even inability 
to use them, and sometimes more or less paralysis of the bladder. These 
paraplegic symptoms pass off in a few days. Vomiting is also a common 
symptom in this, stage, and one also of diagnostic value. It occurs at 
short intervals for twenty-four to thirty-six hours. The same symptom is 
common in scarlet fever, and not infrequent in measles, but in both these 
maladies irritability of stomach is much less persistent than in smallpox ; 
vomiting does not occur in normal rubeolous and scarlatinous cases more 
than once or twice. 

The tongue is covered with a moist fur. If the disease is to be discrete, 
constipation is commonly present in the stage of invasion ; if confluent, 
diarrhoea is a common symptom, continuing till the fourth or fifth day, or 
even longer. Roseola or erythema sometimes occurs in this stage, and 
this may lead to error of diagnosis, the disease being mistaken for one of 
these cutaneous affections, or even for scarlet fever. The symptoms in 
the stage of invasion are usually more violent in confluent than in discrete 
variola, but there are exceptions. 

Stage of Eruption The eruption commences about the third day, 

earlier in some cases, later in others. The average duration, therefore, 
of the first stage is somewhat shorter than in measles, but considerably 
longer than in scarlet fever. Sydenham has stated, and observations 
show the truth of the remark, that the shorter the first stage, the more 
severe the disease will prove to be ; and, conversely, the longer the period, 
the milder will be its form. Therefore, if the eruption begin on the 
second day, it will, as a rule, be confluent ; if not till the fifth or sixth 
day, it will be scanty and the disease light. 

The eruption commences in minute red spots, somewhat like those of 
lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is 
sometimes, especially in young children, first observed in the folds of the 
skin, as about the genitals or in the groin. If the cuticle is irritated, 
as by a sinapism, the eruption often appears first upon this part of the 
surface and in greater abundance than elsewhere. The eruption com- 
mencing in a minute reddish point, as stated above, rapidly enlarges, and 
soon its central part begins to be indurated and raised. It feels round 
and hard to the finger, is tender, and its diameter does not ordinarily 
exceed two lines. This is the papular stage. The papulas increase and 
become more elevated, and in twenty-four to forty-eight hours from the 
commencement of the eruptive stage they become vesicular. On the fifth 



200 VARIOLA. 

day of the eruption, or eighth of the disease, the vesicle has attained its 
full size. Its diameter is then about one-fourth of an inch, and its eleva- 
tion is two or three lines. Its base is circular and indurated, and it is 
surrounded by a narrow zone of inflammation, indicated by redness and 
tenderness of the skin. The pock commonly, as it passes from the papu- 
lar to the vesicular stage, loses its acuminate form, and becomes depressed 
in the centre, but in most cases, mixed with the umbilicated vesicles, are 
some which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola and 
in varioloid, the symptoms which accompanied the stage of invasion abate ; 
the fever, headache, pain in the back, and thirst cease, and the appetite 
returns. In the confluent form, the febrile action continues with little 
abatement. 

Simultaneously with the eruption upon the skin, an eruption also occurs 
upon the buccal and faucial surface, and often upon that of the air-pas- 
sages. It occurs sometimes, also, upon the conjunctiva, producing dan- 
gerous ophthalmia, and even ulceration, with loss of sight, and upon the 
mucous surface of the genital organs. The form which it presents upon 
mucous surfaces is somewhat different from that upon the skin. There is 
at first a deposit of fibrin, producing a small, round, grayish spot at the 
point of eruption — firm, slightly elevated, and covered, if not by the entire 
mucous membrane, at least by its epithelial layer. Ulceration soon occurs, 
as in ulcerous stomatitis, and, if the patient live, the reparative process 
succeeds, as in simple ulcers. The eruption upon mucous surfaces increases 
considerably the suffering of the patient, in consequence of the tenderness 
of the ulcers ; and if its seat be the surface of the larynx or trachea, it 
may be the immediate cause of death, especially in young children, by 
obstructing respiration. 

The cutaneous eruption has been traced to the vesicular stage. On or 
about the fifth day of the eruptive period, or eighth of smallpox, the 
vesicles gradually change their character, their contents becoming thicker 
and turbid. At the same time they increase somewhat in size, and the 
central depression disappears. This is designated the stage of maturation, 
or of suppuration, though it is known that the turbidity is due chiefly to 
another substance than pus. The pock having undergone these changes, 
is termed the pustule. 

In discrete variola, and in varioloid, the fever returns during the pus- 
tular stage ; or, if the form of the disease be confluent, and the fever has 
continued, it now becomes more intense. The return of fever, or its in- 
crease, is denoted by increased frequency of pulse, elevation of tempera- 
ture, dryness of skin, anorexia, and thirst. A tendency to constipation 
remains throughout the disease in varioloid and discrete variola ; in the 
confluent form, diarrhoea more frequently occurs, which, if it continue, is 
an unfavorable prognostic sign. 



STAGE OF DESICCATION. 201 

Other changes occur. The pustules increase somewhat in size, and 
become more globular. Some of them, when most distended, break 
through friction of the clothes, or scratching of the child, and, their con- 
tents escaping, add to the loathsomeness of the disease. There is in the 
pustular stage more or less redness of the surface between the eruptions, 
and, except in the mildest cases, tumefaction from subcutaneous infiltra- 
tion occurs. In the confluent form, at this period, the features are often 
so swollen that the friends would not recognize the patient. The eyelids 
may be so oedematous that the eyes are for a time concealed from view. 
This oedema of the surface is not altogether absent in the vesicular stage, 
but it increases during the time of maturation, after which it subsides. 

Stage of Desiccation This immediately succeeds the full develop- 
ment of the pustules. The liquid portion of the contents of the pustules, 
which are broken, evaporates, leaving a crust. If there is no rupture, the 
liquid is absorbed, and a scab results, which, though smaller, preserves in 
a measure the form of the pustule. While the pustule desiccates, the sur- 
rounding inflammation rapidly abates. The crusts occur first upon the 
face, and on other parts in the order in which the eruption appeared. 
The odor from the patient, at this time, is peculiar. In the confluent 
form, especially, it is very offensive, and can be noticed at a distance from 
the bedside. Rilliet and Barthez call it nauseous and fetid. As desicca- 
tion progresses, the symptoms, local and general, abate. The pulse and 
temperature, if the case is favorable, return to their normal standard. 
The cough, hoarseness, and thirst disappear, while the appetite returns ; 
the sleep is more tranquil, and the functions, generally, are more regu- 
larly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brownish 
appearance, are successively detached. This period lasts several days ; 
sometimes two or three weeks even elapse before all the crusts separate. 
In the meantime the patient gradually recovers his health and former 
strength. After the fall of the crust, the cicatrix underneath presents a 
reddish appearance. This color gradually fades, and there remains an 
irregular depression, or pit, of a lighter color than the surrounding sur- 
face ; and if there has been a full development of the eruption, disfiguring 
the patient for life. 

Such is the clinical history of variola, when it is favorable, and its 
course is regular. The disease is sometimes irregular. In rare instances 
the eruption occurs almost at the commencement of the attack. The 
form is then very apt to be confluent. There are irregularities, also, in 
consequence of diarrhoea, hemorrhages, or other complications. I have 
known the eruption appear first on the limbs, and last on the trunk and 
face, and the appearance of the eruption is not always the same. In the 
anaemic and feeble child it often presents a pale color, with some indura- 



202 VARIOLOID. 

tion at its base, but without the red areola around it, or with this quite 
indistinct. In rare instances the vesicles have a reddish color, their con- 
tents being tinged with blood. This form of variola is designated hemor- 
rhagic. It indicates a profoundly altered state of the blood. The erup- 
tion in this form is of small size, and if the pock is broken, blood oozes 
from it. 

Varioloid — The course of varioloid is similar to that of variola, but 
it is somewhat shorter. It commences with rigors, followed by fever, 
headache, pain in the back, vomiting, drowsiness, and sometimes delirium, 
or even convulsions. The symptoms in the stage of invasion are, indeed, 
the same in character, and often nearly as severe as in variola. With the 
initial symptoms, there is also sometimes a scarlatiniform eruption, so that 
the disease may at first be mistaken for scarlatina. On the third or 
fourth day the variolous eruption commences. The number of pocks is 
commonly few, often not more than twelve to twenty. In the mildest 
form of varioloid, if the physician is not summoned in the stage of inva- 
sion, he is not apt to be called at all, so that the patient may pass through 
the disease in ignorance of its nature. The true character of the malady 
is not ascertained till others are affected, either with variola or varioloid. 

The eruption pursues a more rapid course in varioloid than in the un- 
modified disease. By the fifth or sixth day the pustules are fully developed, 
though often smaller and less likely to be ruptured than in variola. Often, 
in varioloid, the eruption aborts. It remains papular two or three days, 
and then declines, or it may reach the vesicular stage, and decline without 
pustulation. 

The constitutional symptoms in varioloid abate with the commencement 
of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If several 
years have elapsed since the vaccination, its protective power is greatly 
impaired, and varioloid may then exhibit as severe a form as ordinary 
smallpox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease where there has been previous vaccination. It is also applied by 
writers to second attacks, whether the first occurred from infection or 
from variolous inoculation, but such cases are rare. 

Mode of Death Death in smallpox occurs in several different ways. 

The most fatal period is the pustular stage. Feeble children not unfre- 
quently die from exhaustion at or about the time that the pustules attain 
their greatest size. The eruption appears and becomes developed as 
usual, but there are evidences of weakness in the patient, and suddenly 
the progress of the vesicle or pustule ceases. It begins to subside, and its 
walls shrivel. There is evidently absorption, in part, of the liquid con- 
tents. These phenomena are of the gravest character. Death is the 



ANATOMICAL CHARACTERS. 203 

common result, and within twenty-four hours. In other cases death 
occurs from apnoea. The pock increasing in size in the larynx and tra- 
chea, obstructs inspiration, or there may be the formation of a pseudo- 
membrane, as in true croup. This is not an unusual mode of death in 
young children, in whom the calibre of the larynx and trachea is small. 
Sometimes convulsions and coma occur in the last hours of life. In other 
cases the stage of desquamation is reached, but convalescence does not 
occur. The patient each day becomes more anaemic and feeble, and 
finally death results from failure of the vital powers. Again, after small- 
pox has run its course, purpura hemorrhagica maybe developed. Hemor- 
rhages occur from the gums, throat, nostrils. Blood is vomited, and 
evacuated in the stools. I have known death to occur in all these ways, 
but that from purpura is least frequent. Sometimes, as in scarlet fever, 
death occurs suddenly and unexpectedly in confluent, and even in discrete 
variola, when the previous symptoms had apparently been favorable. The 
patient is overpowered by the intensity of the virus. 

Anatomical Characters In those who have died of variola, with- 
out inflammatory or other complication, the heart-clots have been found 
small, dark, and soft. The blood is dark and thin. The vessels of the 
brain and its membranes are injected, so that numerous red points appear 
on the cut surface of this organ. The vessels of the lungs and the ab- 
dominal organs are congested, while the muscles present a deep red color. 
The variolous eruption penetrates more deeply than that -of any other 
exanthematic fever. It has been stated elsewhere that it occurs not only 
on the skin, but often on the surface of the mouth, fauces, and air-pass- 
ages. The mucous membrane in these situations is frequently also the 
seat of catarrhal inflammation, being thickened and softened, and in some 
parts, as the larynx, a pseudo-membrane is occasionally produced, as in 
croup. The inflammation, whether catarrhal or pseudo-membranous, may 
occur without as well as with the presence of the specific eruption. 

The eruption very seldom, perhaps never, appears upon the gastrointes- 
tinal surface, but the solitary follicles and patches of Peyer are often en- 
larged, as in some other zymotic aifections. The liver, spleen, and kidneys 
are commonly congested in those who have died of variola. The spleen, 
especially, is increased in volume and softened ; the kidneys are enlarged, 
as if from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Rilliet and Barthez, 
and others. The vesicle is multilocular, consisting of at least five or six 
compartments, with distinct partitions. Its centre is united by fibrous 
bands to the derm beneath, which union gives rise to the umbilicated ap- 
pearance. The giving way of these minute bands in the pustular stage 
occurs when the form changes from the umbilicated to the convex. In the 
pustular stage also, according to some, a fibrinous formation occurs within 
the pustule ; according to others, this substance is of the nature of the 



204 VARIOLOID. 

epidermis, presenting the appearance of the cuticle when macerated. 
Mixed with this epidermic or fibrinous formation are pus-cells. 

Complications — There are several different complications of variola. 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child, it is slight, commencing with or about the 
time of the eruption, and disappearing in from one to four or five days. 
Ophthalmia is another complication. Simple conjunctivitis, often quite 
intense, may occur in consequence of pustules developed under the lids. 
This inflammation subsides without injury to the eye, as the primary dis- 
ease abates. A more serious inflammation occurs at an advanced stage 
of the disease, commencing in or near the desquamative period. This 
produces more or less chemosis, and sometimes opacity or ulceration of 
the cornea. A similar inflammation may occur in the ear, giving rise to 
otorrhcea, and even in some patients to rupture of the drum of the ear. 
Abscesses in the subcutaneous connective tissue have been occasionally ob- 
served, especially in the confluent form. Subcutaneous infiltration and 
feebleness of constitution favor their occurrence. Suppuration within the 
joints is a somewhat rare complication or sequel, rendering convalescence 
protracted, if, indeed, the case is not fatal. 

M. Beraud has published a memoir to show that orchitis in the male and 
ovaritis in the female may complicate variola. These inflammations are 
believed to be accompanied by a small and imperfect variolous eruption 
upon the tunica vaginalis and the peritoneal covering of the ovary. Trous- 
seau states that he has often met this complication in the male, since his 
attention was called to it. It is mild, and subsides with the disappearance 
of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneu- 
monia, pharyngitis, purpuric hemorrhages, gangrene of the mouth or 
other parts, oedema pulmonum, and oedema glottidis are occasional com- 
plications, some of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child, the greater the danger. Trousseau says: " Confluent variola, and 
even discrete variola, are almost always fatal in individuals less than two 
years old." Above the age of three or four years discrete variola usually 
ends favorably, but the confluent form is still, as a rule, fatal. Varioloid 
in the child is a mild disease, terminating favorably in a large proportion 
of cases. It is milder at this age than in the adult, on account of the 
more recent period of vaccination, and if a case of supposed varioloid is 
severe, and the eruption abundant, it is probable that the vaccination was 
spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are, great violence of the 
initial symptoms ; early appearance of the eruption ; an abundant erup- 
tion, especially if pale, and without swelling of the surface ; rapid decline 



TREATMENT. 205 

of the eruption in the vesicular or pustular stage ; hemorrhagic eruption, 
or hemorrhages from the surfaces ; fever continuing after the appearance 
of the eruption ; diarrhoea persisting beyond the third or fourth day ; de- 
lirium or great drowsiness ; a frequent and feeble pulse ; and, finally, ob- 
structed respiration — if slow, indicating a pseudo-membrane or variolous 
eruption in the larynx or trachea ; if rapid, indicating bronchitis or 
pneumonia. 

Diagnosis The diagnosis cannot be made with certainty prior to the 

eruptive stage. If, however, smallpox is prevalent, if the patient has not 
been vaccinated, and the symptoms which pertain to the period of inva- 
sion are present, as headache, pain in small of back, repeated vomiting, 
drowsiness, and perhaps convulsions, there is ground for the gravest sus- 
picion. If, in addition to these symptoms, reddish points begin to appear 
on the second or third day, the diagnosis may be made with confidence. 
At this early period, even before there is any distinct cutaneous eruption, 
ash-colored spots may sometimes be observed on the buccal or faucial 
surface, the commencement of the variolous eruption ; these possess con- 
siderable diagnostic value. 

The scarlatiniform efflorescence, in the first stage of variola, sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis, and the appearance of the variolous eruption soon after the 
efflorescence, correct the diagnosis. Smallpox has, in the beginning of the 
eruptive period, sometimes been mistaken for measles. The points involved 
in the differential diagnosis have been presented in treating of that disease. 
After the development of the eruption, it may be mistaken for varicella. 
The eruption of varicella is, however, preceded by symptoms which are 
milder and of shorter duration, and its appearance is different. It is 
irregular, instead of round ; is not umbilicated, and it does not have the 
round, inflamed, and indurated base, which characterizes the variolous 
eruption. The eruption of ecthyma is sometimes umbilicated, but the 
symptoms of ecthyma and variola, and the progress of the eruptions in the 
two diseases, are very different. 

Treatment. — Smallpox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pallia- 
tive. In the first stages of the disease, the diet should be simple ; gentle 
laxatives and refrigerant drinks are required if there is much febrile ex- 
citement. Lemonade is a grateful drink, and may be given in moderate 
quantity. Spiritus Mindereri in carbonic acid water may be allowed. As 
the disease advances, more nutritious food should be recommended ; and 
in severe cases carbonate of ammonia, and even alcoholic stimulants, are 
required. 

As confluent smallpox is nearly always, and the discrete form often, fatal 
in infancy, the physician should carefully watch the progress of the case 
in the infant. By judicious treatment, some, in this period of life, may be 



206 VARIOLOID. 

saved, who otherwise would perish. In the infant depressing measures 
should be avoided. A laxative may be given, at first, if there is much 
fever, and the bowels are constipated ; but the diet should be nutritious, 
and many soon require tonics and stimulants. If the pulse become more 
frequent and feeble, or if, with frequency of the pulse, the face and extre- 
mities become cool ; or if, in the vesicular or pustular • stage, the eruption 
suddenly subsides, alcoholic stimulants must be immediately employed, or 
the patient dies. 

Such is an outline of the constitutional treatment required in smallpox. 
Sydenham inculcated a mode of treatment which experience has shown to 
be injurious in infancy and childhood. He had observed that the severity 
of the disease was ordinarily proportionate to the amount of eruption, and 
concluded from this fact that measures which retarded the development of 
the eruption were salutary ; cold drinks, a cold apartment, scanty covering 
of the body, cathartics that caused derivation of blood from the surface, 
even sometimes the abstraction of blood, were considered according to 
Sydenham's theory, to be useful as means of preventing full development 
of the eruption. 

Sydenham's treatment, however appropriate it might sometimes be in 
case of robust adults, is unsuitable for children, because they do not, as a 
rule, tolerate, in this disease, measures which reduce the strength. More- 
over, smallpox is rendered more dangerous by what Rilliet and Barthez 
designate perturbating treatment — treatment which renders it abnormal. 
The regular appearance and development of the eruption are requisite in 
order that the case may progress favorably. On the other hand, the op- 
posite plan of treatment, which families, if left to themselves^ are apt to 
adopt — namely, the employment of measures to promote perspiration, as 
hot drinks, and confinement in a heated room — is also injurious. 

The patient should be kept in a temperature such as he has been accus- 
tomed to, and such as is agreeable to him ; his diet should be simple and 
nutritious ; laxative medicine should only be given to procure the natural 
evacuations. In smallpox, as in all infectious diseases, free ventilation of 
the apartment is required. 

While the general eruption in smallpox should not be interfered with, 
it is proper to endeavor to diminish, so far as possible, the size of the pocks, 
on parts exposed to view, so as to prevent disfigurement. Professor Flint, 
in his Treatise on the Practice of Medicine, has published an excellent 
summary of the various measures which have been recommended for ac- 
complishing this end. First : The opening and breaking up of the vesicle 
by means of a fine needle. This is tedious practice in confluent variola, 
but it can readily be performed in the discrete form — at least as regards 
the vesicles upon the face. This treatment was proposed by Rayer, and 
it is recommended by many who have tried it. Secondly : After the 
evacuation of the liquid, the cauterization of the vesicle by a pointed stick 



TKEATMENT. 207 

of nitrate of silver. Rilliet and Barthez say, in reference to this mode of 
treatment, "Individual cauterization of the pustules is, on the other hand, 
an almost infallible means of causing them to abort. To be successful, it 
is necessary to penetrate into the interior of the pustule with a pointed 
crayon of nitrate of silver, in order to cauterize the derm. ... It is only 
the first or second day of the eruption that it (cauterization) has certain 
success ; nevertheless, we have often seen it succeed the third or the fourth 
day, or even the fifth." 

Thirdly : The application of tincture of iodine once or twice daily over 
the eruption when in the papular stage. Some writers, who have em- 
ployed iodine, state that it does not prevent pitting, but diminishes it. Its 
favorable effects are produced by coagulating the contents of the papule. 
Fourthly : The exclusion of light and air by means of a plaster. A mix- 
ture containing tannate of iron has been employed for this purpose in one 
of our hospitals. This produces a black mask. Light and air may also 
be excluded by smearing the face with sweet, oil, and dusting twice daily 
upon the oiled surface a powder containing equal parts of subnitrate of 
bismuth and prepared chalk. -Fifthly : The application of mild mercurial 
ointment upon the face or other parts of the surface, where it is desirable 
to render the eruption abortive. This mode of treatment does diminish 
the size of the vesicles and the pitting, but I should not recommend it for 
children. I have known in the adult severe mercurialization from its em- 
ployment for four or five days, and, though young children do not exhibit 
so readily the effects of mercury, the use of the ointment, unless for a very 
limited period, increases, in my opinion, their feebleness, and diminishes 
the chance of their recovery. Calamine made into a paste with sweet oil 
is said to be equally effectual with mercurial ointment, and it produces no 
constitutional effect. Its effect is obviously similar to that of the bismuth 
and chalk employed with sweet oil as stated above. Also, I have em- 
ployed pulverized charcoal made into a thin paste with sweet oil or glyce- 
rin, and applied daily or twice daily to the face. It effectually excludes 
the light, and the result appeared to be good as regards pitting, but it is a 
disagreeable application. Curschmann recommends as preferable to any of 
these methods, the use of iced compresses to the face and hands. The pain, 
redness, and swelling are diminished by their use, but without change in 
the copiousness of the eruption. (Ziemsse?i' s Encyclop.) If fissures or 
excoriations occur, an application may be made of oxide or carbonate of 
zinc in glycerin, one drachm to the ounce. 

The prevention of smallpox, so far as practicable, is one of the import- 
ant incidental duties of the physician. Isolation of the patient, and pre- 
cautions in reference to his clothes and bedding, are imperatively required, 
so great is the contagiousness of this disease. The only certain means of 
prevention is confessedly vaccination, and providentially the incubative 
period of the vaccine disease is much less than that of variola. Therefore, 



208 VACCINIA. 

smallpox may be prevented after the virus is received in the system, by 
timely and successful vaccination. Vaccination, at any period between 
the time of exposure and the commencement of the symptoms of invasion, 
will either prevent the occurrence of smallpox or modify it. If the symp- 
toms of invasion have already commenced, it is uncertain whether it pro- 
duces any modifying effect. 



CHAPTER V. 

VACCINIA. 



Vaccinia is a mild eruptive disease, which occasionally occurs among 
cattle, and has been propagated from them to man. It is characterized 
by the appearance upon the surface of one or more papules, which soon 
become vesicular, and then pustular. It is communicable by contact, but, 
unlike the other eruptive fevers, it is not contagious through the air. It 
is inoculable, both by the liquid contained in the vesicle, which is desig- 
nated vaccine lymph, and by the scab which results from the desiccation 
of the pustule. 

To Gloucestershire, England, the honor belongs of discovering and 
utilizing the fact that vaccinia, a mild and comparatively harmless 
disease, is transmissible from the cow to man, and that it affords protection 
from smallpox. It appears that a vague opinion prevailed among the 
farmers of this dairying section, that a disease, which has since been de- 
signated vaccinia, was occasionally received from the cow in milking, the 
virus passing from a pustule on the teat to a sore or chap on the hand of 
the milker, and that those who thus contract the disease receive immunity 
from smallpox. As usually happens with important discoveries, so dull 
of apprehension is human intellect, these people, to whom Providence had 
revealed so important a fact, were blind to its real value. Finally, in the 
year 1774, Benjamin Jesty, whom the world has not sufficiently honored, 
" an honest and upright man," according to his epitaph, a farmer of Glou- 
cestershire, had the courage to vaccinate his wife and two children. His 
excellent moral character did not shield him. He was regarded by his 
neighbors as an inhuman brute, who had performed an experiment on his 
own family, the tendency of which might be to transform them into beasts 
with horns. 

The first essay in vaccination appears to have been entirely successful, 
but the prejudice against the operation continued. A fifth of a century 
passed, during which there was no extension of the benefits of this great 
discovery. At last, towards the close of the last century, Dr. Edward 



VACCINIA. 209 

Jenner, a physician of Gloucestershire, and inoculator of his district, began 
to investigate this disease of the cow, about which little was known, and 
the grounds for the belief that it afforded protection from smallpox. For- 
tunately for the world, Jenner had been educated under John Hunter, 
and had learned from his great master to study nature rather than books, 
to be guided by experience and observation rather than by the dogmas of 
his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, twenty- 
two years after Benjamin Jesty had lost his good name among his neigh- 
bors for vaccinating his own family. The popularizing of vaccination, 
mainly through Jenner's perseverance, affords one of the most interesting 
and instructive chapters in the history of medical science. How he went 
up to London, full of the importance of the discovery, and was there 
advised by his medical friends to desist from his wild schemes, lest he 
should injure the reputation which he had gained from a creditable paper on 
the habits of the cuckoo ; how he was allowed to vaccinate in the hospital 
wards, and gained some adherents to the new faith among the leading 
physicians of the metropolis ; and finally, how, as the claims of vaccina- 
tion began to be recognized, at the close of the last century and commence- 
ment of the present, a most acrimonious discussion arose, which filled all 
the medical journals of that period. The opponents of vaccination resorted 
to every device to prevent the acceptance of Jenner's views. They at- 
tempted to prejudice the people against them by specious arguments, by 
ridicule, and even by caricatures. One" of the leading journals contained 
the picture of a cow covered with sores, and devouring children, and it 
was urged that vaccination was a bestial operation, degrading man to the 
level of the brute. But the truth had gained a firm hold, and the practice 
of vaccination extended. 

The discovery of vaccinia, and of its protective power, cannot be too 
highly appreciated. It has, probably, done more to relieve human suffer- 
ing than any other discovery of the last one hundred years, unless we 
except that of anaesthetics, and more to save human life than any other 
instrumentality of a purely physical kind. 

The fact was established in the time of Jenner that the virus of small- 
pox inoculated in the cow produced vaccinia, which, in its propagation 
back to man never returned to its original form, but always remained vac- 
cinia. Moreover, Jenner believed that the disease known in the horse as 
the grease was identical in nature with vaccinia in the cow. He failed, 
however, in his experiments to communicate vaccinia from the horse, but 
other experiments have been more successful. In 1801, a Dr. Loy, of 
the county of York, England, met two cases of vaccinia in persons who 
had taken care of a horse affected with the grease, and, from the lymph 
which he obtained, was able to produce vaccinia in the cow. In 180o, 
Viborg, a Danish veterinary surgeon, after many failures, succeeded also 
14 



210 VACCINIA. 

in communicating vaccinia to the cow by means of the virus taken from a 
horse. 

From this time little light was thrown on this subject till within the last 
twenty years. Although Loy and Viborg, and perhaps a few others, had 
recorded their success, other experimenters had failed to communicate vac- 
cinia from the horse. In the absence of additional cases, the profession 
began to question whether there might not have been some error in the 
observations of the gentlemen whose names I have mentioned, and the 
problem was still regarded as undetermined, whether a disease identical 
with vaccinia occurred in the horse, or a disease which might communi- 
cate vaccinia to the cow or to man. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, which must be regarded as conclusive. In 1856, in the 
department of d'Eure-et-Loir, France, M. Pichot was consulted by a boy 
who had on the back of his hands vaccine pustules, which had apparently 
reached the eighth or ninth day. He had not taken care of nor been in 
contact with a cow, but had a few days before taken care of a horse affected 
with the grease. Vaccination was performed by means of the lymph taken 
from these pustules, and genuine vaccinia was produced. 

Again, in 1860, an epidemic prevailed among the horses in Riemes and 
Toulouse, France. A mare sickened with the disease, and there was swell- 
ing of the hough, with discharge of sanious matter. M. Delafosse vacci- 
nated two cows with this matter, and communicated genuine vaccinia. 
This epidemic was believed by the veterinary surgeons to be an eruptive 
fever, differing in its nature somewhat from the disease or diseases which 
have ordinarily been designated the grease. It has been conjectured that 
two or more distinct affections of the horse have the same appellation, one 
of which, it is now admitted, is identical with vaccinia of the cow, and 
may communicate it. And the reason why so many experimenters have 
failed to vaccinate the cow from the horse is that they have used the virus 
of the wrong disease, or have taken matter from horses which had been 
affected with the true disease, but from ulcers which had lost their specific 
character. 

Prior to the time of Jenner variolous inoculation was practised in most 
civilized countries, since variola produced in this way was found to be milder 
than when arising from infection. This practice is now obsolete ; forbidden 
in some places by legislative enactments. It is superseded by vaccination. 
Vaccination, or the introduction of vaccine lymph into the system, is 
quickly and conveniently performed by scarifying with a lancet, and press- 
ing into the incisions the lymph, or a little of the scab pulverized and 
dissolved in a drop of cold water. It may also be performed by scraping 
off the epidermis with the edge of the instrument till the blood begins to 
ooze ; and also, though with less certainty of success, by puncturing the 



APPEARANCES — SYMPTOMS. 211 

skin with the point of the lancet, or by an instrument called the vacci- 
nator. 

If the child has a vascular nrevus, this may be selected as the point of 
vaccination. Unless of large size, it can usually be cured by the inflamma- 
tion which vaccinia produces. Statistics collected by Simon, as well as 
Marson, show that of those who contract varioloid, the larger the number 
of vaccine cicatrices the milder the disease, and the less the proportionate 
number of deaths. In Simon's statistics of those who stated that they had 
been vaccinated, but who presented no cicatrix, 21| per cent, died ; of 
those who had one cicatrix, 1\ per cent, died ; of those who had two, 4^- 
per cent, died ; of those who had three, If per cent, died ; while of those 
who had four or more cicatrices, only j per cent. died. These statistics 
would seem to indicate the propriety of vaccinating in several places. But, 
so far as appears, when two or more cicatrices were observed, the patients 
may have been vaccinated at different times, at intervals, perhaps of seve- 
ral years, and if so, the inference would not follow that more complete pro- 
tection is produced by vaccinating in several places than in one. More- 
over, if vaccination is performed in the usual manner by several incisions 
on the arm, and the virus is fresh and active, usually two or more distinct 
vesicles arise, which unite in their development, and probably protect the 
system as much as if they were separated by a wider space. 

Appearances — Symptoms In genuine vaccination no effect is ob- 
served, except the slight inflammation due to the operation, till the close 
of the third day. Then the specific inflammation commences. This is 
indicated by a small red point, at first scarcely visible, indurated and 
slightly elevated, as determined by the touch, rather than by the eye. 
This increases, and on the fifth day the cuticle over the inflamed part 
begins to be raised by a transparent and thin liquid. The vesicle increases 
in diameter, and by the sixth day presents an umbilicated appearance, 
and is surrounded by a faint and narrow red zone. At the close of the 
eighth day the vesicle is fully developed. Its size varies considerably. 
It is usually from a sixth to a third of an inch in diameter, and oval or 
circular. If the vaccination has been performed by incisions, the size of 
the matured vesicle may be considerably larger, and its shape irregular, in 
consequence of the union of two or more vesicles. The eruption now pre- 
sents a whitish or pearl-colored appearance, due to the whiteness of the 
cuticle, and the transparence of the liquid underneath. If the vaccination 
was performed by incisions, it is not unusual to observe over the centre of 
the vesicle, and adhering to it, a small yellowish scab, which has resulted 
from the scarification, and which contains none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, com- 
monly eight or ten, with complete partitions, so that there is no intercom- 
munication. On the ninth day the inflamed areola becomes more distinct, 
and its diameter rapidly increases. Its color is deep red, its temperature 



212 VACCINIA. 

is considerably elevated, and it is accompanied by more or less induration 
of the subcutaneous tissue, and it is tender to the touch. On the tenth 
day the pock has reached its full development. The areola then extends 
from one to two inches away from the vesicle, becoming fainter at its outer 
circumference, and gradually disappearing in the healthy skin. The shape 
of the outer circumference of the areola is irregular, projecting further at 
one point than another, though its general form is circular. 

On the tenth day, when the inflammation has reached its maximum, the 
heat, itching, and tenderness in and around the pock are such that the 
child is often feverish and restless. Occasionally the glands of the axilla 
become swollen and tender. In other cases, in which there is but a mode- 
rate amount of inflammation, the constitutional disturbance is slight. 

At the close of the tenth day, or on the eleventh, the imflammation 
begins to decline ; the areola becomes narrower and then disappears ; the 
induration and tenderness abate ; and with this change the pustule desic- 
cates, its liquid is absorbed, and there results a brownish or 'a dark ma- 
hogany-colored scab, which is detached, ordinarily, between the fourteenth 
and twenty-first days. The cicatrix, at first reddish, like all recent cica- 
trices, gradually becomes paler, and remains whiter than the surrounding 
integument. It presents several minute depressions or pits, which indicate 
the genuineness of the vaccination. 

Anomalies, Complications, and Sequels The vesicle is often 

broken, accidentally, or by the nails of the child. If the top of the vesicle 
is destroyed, or most of the compartments are opened, the inflammation is 
commonly increased, considerable suppuration occurs, and there results a 
large, irregular, yellowish scab, consisting of the virus mixed with desic- 
cated pus. This scab is entirely unreliable, and unfit for the purpose of 
vaccination, though the protective power of the disease is not diminished 
by injury of the vesicles, even if it is totally destroyed. The cicatrix which 
results from extensive injury of the vesicle is apt to be large, and without 
the indented points which characterize the normal cicatrix. 

In rare cases when the inflammation which surrounds the vesicle is in- 
tense and deep seated, suppuration occurs in the subjacent connective tissue, 
giving rise to an abscess. This abscess is commonly of small size, but it 
increases the fretfulness and constitutional disturbance which attend vac- 
cinia. This subcutaneous suppuration is believed to occur most frequently 
in those who have a scrofulous or vitiated state of system. Inflammation 
of the lymphatic glands of the axilla I have spoken of as not infrequent 
in vaccinia. This sometimes proceeds to suppuration, producing an un- 
pleasant, though not serious, complication. 

It sometimes happens that vesicles appear in other parts besides the 
points where the virus was inserted. These supernumerary vesicles com- 
monly occur w r here the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On 



ANOMALIES, COMPLICATIONS, AND SEQUELS. 213 

the eleventh day he was astonished to find twenty-seven vaccine pustules 
on the face, trunk, and limbs. This infant had, however, before the vac- 
cination, a simple non-specific eruption over the whole body, and it was 
believed that it had produced these vaccinations by transferring the lymph, 
with its nails, to the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts of 
the surface simultaneously with or soon after the vesicle, and in a few days 
declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation, or from the inflammation caused by the vesi- 
cle, when the virus possesses no deleterious property ; and, again, it may 
result from some unknown element in the virus. It may occur imme- 
diately after the operation, when it commonly prevents the working of 
the virus, or during the vesicular or pustular stage ; or, again, after desic- 
cation and separation of the scab. I have observed it commencing at all 
these periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably re- 
ferred by the friends to the virus employed, and the physician who has 
had the misfortune to vaccinate is often unjustly blamed. In many of 
these cases there was a strong predisposition to erysipelas at the time of 
the vaccination, and the operation or the inflammation which accompanied 
the normal development of the vesicle served simply as an exciting cause. 
Erysipelas would occur as soon from a non-specific sore ; indeed, we not 
unfrequently are called to cases of this disease in young children, which 
commenced from non-specific sores upon the genitals, or on one of the 
limbs. That the fault is not in the virus employed, is evident from the 
fact that other children, vaccinated with the same, have simple uncompli- 
cated vaccinia. 

Sometimes, on the other hand, the cause of erysipelas, whatever it may 
be, exists in the virus. For further facts in reference to this subject, the 
reader is referred to our remarks on erysipelas. 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia 
has terminated, or for a little time subsequently, but it then constitutes a 
very serious sequel. A physician of this city, well known in this com- 
munity as skilful in the diagnosis and treatment of skin diseases, and 
therefore not likely to be mistaken as regards the nature of the diseases, 
states that he communicated syphilis to two infants by vaccinating with 
the same scab. Both had the characteristic syphilitic eruption. In 
January, 1868, an infant was brought to Prof. Alonzo Clark's clinique, 
in this city, having syphilitic rupia, which, in the opinion of the physi- 
cians present, was undoubtedly the result of vaccination. 

Trousseau relates the case of a young woman, eighteen years old, who 
was Vaccinated with virus taken from an infant apparently in perfect 



214 VACCINIA. 

health. The vaccination was unsuccessful ; but twenty -three days subse- 
quently his attention was called to an eruption which had appeared in 
two places on the woman's arm, corresponding with the points where the 
virus had been inserted. The eruption was that of ecthyma, which, by 
the next examination, which was five days subsequently, had been trans- 
formed into rupia. The axillary lymphatic glands were tumefied and 
indolent, and finally roseola appeared, which removed all doubts as to the 
syphilitic character of the disease. There was syphilitic infection, which 
first manifests itself in the points where vaccination had been performed 
{Article de la Vaccine). It is not ascertained in Professor Clark's case, 
nor is it stated in Trousseau's, whether the lymph or scab was employed 
for vaccination. There can be little doubt that the pure lymph never 
communicates anything but vaccinia, and if by vaccination any other 
disease is imparted, a little blood has mingled with the lymph, or the 
scab has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having a 
diameter of more than two lines. Occasionally the development of the 
vesicle is retarded. It does not appear till two or three days later than 
the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles and 
scarlet fever, pursuing its course after the subsidence of the exanthem. 
On the other hand, it arrests the paroxysmal cough of pertussis, which 
returns when the pock begins to desiccate. Eczematous eruptions some- 
times occur after vaccinia, as they often do after the other eruptive fevers ; 
or, if already present, they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the first 
vaccination, is successful. A genuine vaccine eruption results, which is 
smaller the more advanced the primary disease. This second eruption 
overtakes the first. On the ninth day the susceptibility to vaccinia is, in 
most cases, lost ; so that vaccination performed on the tenth, or subsequent 
days, is unsuccessful. 

As a rule, an acute contagious disease occurs only once in the same 
individual. Vaccinia is an exception. In most cases, after a few years, 
it can be produced a second time ; and cases of a third or fourth success- 
ful vaccination, at intervals of a few years, are not uncommon. Now, 
subsequent cases of vaccinia differ from the first, which has been described 
above. The period of incubation is shorter, and the vesicular, pustular, 
and desiccative stages succeed each other more rapidly, so that the whole 
period of the disease is less. The variation from the appearance and 
course of the first vesicle is proportionate to the degree of protection 
which the first vaccination still affords, both as regards smallpox and 



SUBSEQUENT VACCINATIONS. 215 

vaccinia. If several years have elapsed since the first vaccination, and 
the protective power which it afforded is nearly lost, the second vaccinia 
differs but little from the first. If, on the other hand, the first vaccina- 
tion still affords nearly complete protection, the result of the second is 
slight ; the eruption is insignificant, lacking the characteristic appearance 
of the vaccine vesicle, resembling a common sore, and disappearing within 
a week. It is not accompanied by the inflamed areola, or any appreciable 
constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to the 
fact that the lymph or scab employed is useless. It has spoiled by keep- 
ing, or never has been good. In other cases it is due to a lack of suscep- 
tibilitv in the person. Some take vaccinia with difficulty, and only after 
several vaccinations ; just as children, though fully exposed, often fail to 
take measles or scarlet fever, on account of a condition of the system 
which prevents the reception of the virus, or antagonizes and controls its 
action. In some instances, after vaccination, an eruption is produced, 
which may or may not be genuine ; but it immediately becomes purulent, 
and is soon broken. A large, yellow, uneven scab results, having none of 
the appearance and containing little or none of the vaccine virus. This 
scab, as well as the liquid matter which preceded the formation of the 
scab, is utterly useless for the purpose of vaccination, and, if so employed, 
will probably cause a sore from its irritating effect, but not of a specific 
character. If, in place of the true vaccine vesicle, the eruption presents 
the appearance which I have described, namely, that of a pustule, soon 
breaking and forming a large, irregular, yellowish scab, the vaccinia — if 
it is correct so to designate it — must be considered spurious. A sore has 
been produced by the animal matter which was employed in the vaccina- 
tion along with the virus, which has modified the action of the virus, and 
probably has rendered it useless as a means of protection ; or there may 
have been no virus inserted with this animal matter. The physician should 
in such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of the 
child are often satisfied with the result. They see an eruption following 
the vaccination, accompanied by considerable inflammation, and leaving 
a cicatrix. Unless undeceived by the physician, they are apt to remain in 
the belief of the child's security, until, perhaps, it takes smallpox. Such 
cases, obviously, tend to diminish the confidence which the public should 
have in vaccination as a means of protection from smallpox, and on ac- 
count of their frequent occurrence it is important in all cases that the phy- 
sician should see the result of his vaccination. It has been proposed, as a 
means of determining the genuineness of the vaccinia, to revaccinate when 
the eruption begins, and if the first is genuine, the second will overtake it. 
This is called Brice's test ; but it is not necessary, since the physician, 
familiar with the appearance of the true vesicle, can determine at once its 
genuineness by the sight. 



216 VACCINIA. 

Protection from Vaccination — Revaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate smallpox from the 
community, so that it would be interesting only to the medical historian 
as a scourge of past ages. This result, however, is not achieved. As a 
rule, the greater the benefit of any measure designed to ameliorate the 
condition of mankind, the greater and more numerous are the obstacles 
which diminish its effectiveness. Science is full of examples of this. For- 
tunately these obstacles, as regards vaccination, are not such as to impair 
the confidence of physicians in its protective power, and it is not too much 
to expect that this simple operation will yet be the means of rendering 
smallpox a disease almost unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In the coun- 
try, where there is little danger of exposure to smallpox, it maybe deferred 
till the age of ten or twelve months. In the city, on the other hand, where 
there is constant intercourse of people, and where contagious diseases are 
often contracted in ignorance of the time and place of exposure, an earlier 
vaccination is advisable. Some physicians recommend performance of 
the operation as early as the age of four to six weeks. The objection to 
this is, that if erysipelas occur, so young an infant is apt to perish from it, 
whereas an infant three or four months old ordinarily recovers. For this 
reason I believe that the most suitable age is about four months for the city 
infant, in ordinary times ; but if smallpox is epidemic, vaccination should 
be performed at an earlier age. I have vaccinated even the new-born 
infant when smallpox had broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. 
According to M. Gintrac, varioloid does not occur within two years in those 
who have been vaccinated. It may, however, in exceptional instances, 
occur in a mild form within a few months after vaccination. The protec- 
tion afforded by vaccination gradually diminishes by time, but it does not, 
probably, as a rule, cease entirely. Varioloid, however, occurring thirty 
or forty years after a successful vaccination, is apt to be severe, and it may 
even be fatal, showing that it has been but slightly modified. In other 
cases, even after so long an interval, the symptoms present a degree of 
mildness which indicates that the protective power of the vaccination is 
not entirely lost. 

If a second vaccination is practised soon after the scab from the first 
vaccination has fallen, it will usually produce no result, but in other cases 
it gives rise to a little redness, swelling, and induration, which show that 
vaccinia has been reproduced, though in a very mild and insignificant 
form. It is probable that in these cases varioloid might also occur by 
exposure, though with a mildness corresponding with that of the vaccinia. 
The longer the period after the first vaccination, the greater the number of 



SELECTION OF VIRUS. 217 

those in whom a second vaccination is effective, and, as has already been 
intimated, the greater also the liability to the variolous disease if a second 
vaccination is not performed. Therefore a second vaccination should be 
performed about the sixth or eighth year, and again between the fifteenth 
and twentieth year. And if smallpox is epidemic, it is proper to vacci- 
nate all who have not been vaccinated within three or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided that it 
can be obtained fresh. The scab is more easily preserved, and, therefore, 
if the lymph and the scab are old, the latter is to be preferred. The lymph 
should, if the vesicle is sufficiently developed, be taken on the fifth day. 
It may also be taken on the sixth, seventh, or even eighth day, provided 
that the areola has not formed. The lymph of the fifth day acts with 
greater energy, though that of the sixth or seventh day is not much infe- 
rior. Lymph obtained after the formation of the areola is less efficient, 
though it may communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph, taken 
directly from the arm and immediately inserted — the arm to arm vacci- 
nation. Lymph can be preserved for a few days on a flattened surface of 
whalebone, or the segment of a quill, and if employed within a week, it 
will usually communicate vaccinia. Lymph may be preserved a longer 
period between two surfaces of glass, but the best way of preserving it is 
in capillary glass tubes. The end of the tube is placed within the vesicle, 
and the lymph ascends by capillary attraction. When a sufficient quan- 
tity is received, the ends are sealed, by holding them for a moment in a 
flame. Care is requisite in doing this, so as not to heat the lymph, as it 
is spoiled by a temperature much above the body. When the lymph is 
used, the ends of the tube are broken, and by blowing gently through it, 
a sufficient quantity is received on the point of a lancet. 

If the scab is genuine, it presents a dark-brown or mahogany color, and 
has a circular, oval, or at least a rounded form ; it is firm, or compact, and 
has a lustre. Soft, yellowish, and irregular scabs are not genuine, and 
those of a dull appearance, or without lustre, have usually spoiled in the 
keeping. The scab is best preserved in soft beeswax, which excludes the 
air, and it should be kept in a cool place. It is the belief of many that 
the vaccine virus gradually becomes weaker by passing successively through 
the human system (Con die, American Journal of the Medical Sciences, 
April, 1865), and that therefore different specimens of virus work with 
different energy, according to the degree of removal from the cow. To 
what extent this view is correct is not fully ascertained, but, certainly, if 
the virus employed continues to produce a small vesicle, attended only 
by a little inflammation, there is reason to believe that the protection 



218 YAEICELLA. 

which it imparts is less than that from virus which works with greater 
energy, and it should be exchanged for such. In New York we are able 
to obtain at any time lymph directly from the heifer. It has never passed 
through human blood, for the original lymph came from cattle in one of 
the provinces of France, where vaccinia was prevailing epidemically. 
The popular objection to vaccination is obviated by the use of this lymph, 
but it works with great energy, producing a large pock, and a sore which 
is often a month in healing. I have found it very reliable, and prefer to 
use it in ordinary cases. 



CHAPTER VI. 



VARICELLA. 



Varicella, chicken-pox or swine-pox, is the shortest and mildest of the 
eruptive fevers. It is highly contagious, so that few children escape who 
are exposed to it. Its period of incubation is from fifteen to seventeen 
days. It is not inoculable, or at least those who have attempted to inoc- 
ulate with the lymph of varicella have failed. I endeavored to commu- 
nicate the disease in this way some years ago, but without result. It 
attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some, to prevail most, immediately before, during, or 
after epidemics of smallpox, and it has been conjectured that it is a 
modified form of variola, and hence its name, which signifies little variola. 
This idea is, however, entertained by few, and it is opposed by the follow- 
ing facts : Varicella may occur after variola, or variola after varicella, 
without any modification, and the two diseases are very dissimilar as 
regards gravity of symptoms and duration. The variolous disease, whether 
smallpox or varioloid, often occurs in the adult ; varicella, on the other 
hand, is a disease of infancy and childhood. Professor Flint states that 
he has observed it in the adult, but its occurrence at this period of life is 
rare. Moreover, varicella and variola have been known to occur simulta- 
neously in the same individual. Such a case was reported by M. Delpech, 
in a memoir published in 1845. 

Symptoms Varicella usually commences with such symptoms as usher 

in ordinary mild febrile attacks, namely, headache, languor, chilliness, 
and sometimes aching in the back and limbs. Fever supervenes, which 
is usually moderate, the pulse rising perhaps to 100 or 112, and the ther- 
mometer showing an increase of temperature, but less than occurs in the 
other eruptive fevers. These symptoms which precede the eruption are 
sometimes absent, or are so mild as to escape notice. The fever usually 



DIAGNOSIS. 219 

ceases on the second day, but it may return on the following night. The 
appetite is rarely lost, and most children continue, more or less, at their 
amusements. 

When the above symptoms have continued about twenty -four hours, the 
eruption appears first over the trunk, and soon afterwards, over the face and 
limbs. The eruption consists of minute papules, which become vesicular 
in the course of a few hours. The occurrence of the vesicular stage is 
nearly simultaneous on all parts of the surface. The vesicles lack the hard 
indurated base of the variolous eruption, though they are sometimes sur- 
rounded by a faint zone of redness. They differ also from the variolous 
eruption in the absence of umbilication, and in irregularity of shape. 
Some are small and acuminate, some hemispherical, and of medium size, 
and others oval or elongated, and of large size. The inflammation is quite 
superficial, not involving the subcutaneous tissue, and scarcely affecting 
the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to that of even 
three lines. They occasionally give rise to slight itching. On the second 
day of the eruption, or third of the disease, the vesicles are still fully de- 
veloped, their liquid contents being nearly transparent. At the close of 
this day the liquid begins to be somewhat cloudy, and its absorption com- 
mences. On the fourth day of the disease desiccation progresses rapidly, 
and by the fifth the liquid has for the most part disappeared, and there 
results a scab, small and thin, of a yellowish-brown color. The scabs are 
soon detached, the redness which indicated their seat disappears, the epi- 
derm which had been raised and removed by the eruption is reproduced in 
its normal state, and in a few days all evidence of varicella is effaced. A 
cicatrix occasionally results, but it is due not to the simple varicellar erup- 
tion, but to a sore produced from the eruption by the scratching of the 
child. 

The number of vesicles varies considerably in different cases. They are 
never, so far as I have observed, confluent ; but they are sometimes so 
abundant in young children that, if the disease were variola, it would be 
called severe discrete. 

Diagnosis — Obviously the only diseases with which varicella is liable 
to be confounded are such as present vesicles at some. stage of their course. 
From the local vesicular eruptions this disease is diagnosticated by the 
fact that the vesicles appear on all parts of the surface. It is sometimes 
mistaken for variola or varioloid or vice versa — a mistake very damaging 
to the reputation of the physician. The points of differential diagnosis are 
the symptoms of invasion — severe, and lasting three or four days in the 
one ; mild, and continuing only one day in the other — an eruption passing 
slowly through its stages from the papulae to the pustular, umbilicated, with 
circular, raised, aud inflamed base, appearing first on the face and neck, 
and not till a day later on the legs, in the one disease ; while in the other 



220 VAEICELLA. 

the evolution, shape, and course of the eruption, as described above, are 
materially different. By proper attention to these distinctive features it is 
rarely difficult to diagnosticate the two diseases. - 

The prognosis in varicella is always favorable. It does not, of itself, 
endanger life, nor seriously incommode the patient; nor does it give rise 
to complications or sequelae. The treatment, therefore, is the simplest 
possible. Mild diet, and a laxative, may be prescribed during the febrile 
period ; but nothing further is required. 



SECTION III. 
NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAPTER I 

DIPHTHERIA. 



Diphtheria is a disease of antiquity, dating back at least as far as the 
commencement of the Christian era. Aretseus, at the close of the first 
century after Christ, described the Malum iEgyptiacum as a malady, 
which occurred chiefly among children, and was characterized by a white 
concretion, spreading over the tonsils, a fetid breath, and in some patients 
by a return of food through the nostrils, and by great dyspnoea, ending in 
suffocation. Since the commencement of the sixteenth century, numerous 
epidemics of it have been observed in Europe and America, and at the 
present time, it is one of the most common and fatal epidemic maladies in 
both continents, while in many localities, especially in large cities, it is 
established as an endemic. 

Age. — Diphtheria is pre-eminently a disease of childhood, a large ma- 
jority of the cases occurring between the ages of two and ten years. Under 
the age of one year the younger the child the less the liability to it, and it 
rarely occurs prior to the fourth month. The age of the youngest patient 
in my practice, so far as I recollect, whose disease was undoubtedly diph- 
theria, was three months and a few days ; but in one instance, I observed 
upon the fauces of an infant of six weeks, whose brother had just died of 
diphtheria, a few white specks, like grains of salt, over each tonsil, which 
disappeared in three or four days, without the occurrence of any marked 
symptoms, by the application of a solution of chlorate of potassa. Certain 
physicians, having charge of maternity wards, have observed a disease, 
occurring in new-born infants, which bears some resemblance to diphtheria, 
but which, if it be true diphtheria, presents anomalous features. Thus, 
Dr. W. S. Bigelow reports in the Bost. Med. and Sury. Journ. for March 
11, 1875, ten cases, occurring between September and December, 1873 
in the Boston Lying-in Asylum, all fatal but two. The prominent symp- 
toms and anatomical characters were : dark hue of skin, hematuria, pseu- 
do-membranous exudation upon certain mucous surfaces, dark green stools, 
spleen enlarged and dark, kidneys engorged, and in some of the cases 



222 DIPHTHEKIA, 

effusion of blood into the pelves of these organs, and along the urinary 
tract, brownish casts in the renal tubes, etc. Since, so far as can be learned 
from the account, the mothers and other inmates were not affected with 
diphtheria, we must doubt the genuineness of these cases. Cases are in- 
frequent after the middle period of life, and old age seems to possess nearly 
an immunity from diphtheria. 

Incubation It is only in exceptional instances that We are enabled to 

ascertain the incubative period of diphtheria. I was enabled to fix it very 
nearly in the following cases which occurred in my practice. A boy of 
nine years was in the same room, about one hour on Saturday, with a child 
who had fatal diphtheria. On the following Tuesday, without any other ex- 
posure, he sickened with a malignant form of the same disease. Mrs. E. 
assisted in nursing a fatal case of diphtheria, from November 11 to 13, 1874, 
after which she returned home, several blocks away. On the evening of the 
15th she complained of sore throat, and on the following day the diphtheritic 
pseudo-membrane was observed over her tonsils. On the 19th the exuda- 
tion had disappeared, and she was convalescent. On the 20th her sister 
residing with her, and who had not been elsewhere exposed, was similarly 
affected, and after three or four days also convalesced. The only other 
case in the family, a boy, sickened with diphtheria on December 2. In 
the first of these cases the incubative period seems to have been from two 
to four days ; while in the last, it was apparently longer. In April, 1876, 
a little girl died of malignant diphtheria in West 41 Street, New York city. 
Her sister, aged one year, remained with her from April 14 to 17, when she 
was removed to a distant part of the city, and placed in a family where 
there was no sickness, and had been no diphtheria. On the night of 
April 24, seven days after her removal, this infant was observed to be 
feverish, and on the following day, when I was called to examine her, the 
characteristic diphtheritic patch had begun to form over the left tonsil. 
In April, 1875, two sisters, aged seven and five years, resided with their 
parents, in a boarding-house, in West 22d Street, New York. A play- 
mate in the same house had symptoms which were supposed to be due to 
a cold, but which w T ere diphtheritic, when one night severe laryngitis oc- 
curred, and ended fatally the next day. The physician who had been 
summoned diagnosticated diphtheria, and the two sisters were immediately 
removed to a hotel. But seven days subsequently, diphtheria commenced 
in the older child. The younger w-as then removed to a distant part of 
the same hotel, but on the sixth or seventh day subsequently she also be- 
came affected w r ith a fatal form of the disease. It is seen that the period 
of incubation in diphtheria, like that in scarlet fever, varies in different 
cases. It is from two to eight days, with perhaps an occasional case out- 
side these limits. 

Nature. — Diphtheria resembles scarlet fever in certain particulars ; in 
its incubative period, as we have seen above, in its variability of type from 



NATURE. 223 

a very mild to a malignant form, in the common seat of its inflammations, 
namely, upon the fauces and nasal passages, in the profound blood poison- 
ing and prostration in the graver cases, and in the frequent occurrence of 
nephritis as a complication or sequel. It resembles both scarlet fever and 
smallpox in the fact that it is communicable both through the atmosphere 
and by contact or inoculation. It resembles erysipelas in the variable- 
ness of its duration, and in the fact that one attack does not protect the 
system from another. In its etiology it resembles typhoid fever, for it is 
not only communicable from person to person, but it is produced by foul 
exhalations, as sewer gases. But while there are certain resemblances, it 
is distinguished from all these infectious diseases by marked peculiarities. 

Diphtheria is primary or secondary. The secondary form most fre- 
quently occurs during epidemics of the other infectious diseases, and as a 
complication of them. Those infectious diseases which are accompanied 
by inflammation of the fauces and air passages, are most liable to this 
complication if they occur in a locality where diphtheria prevails ; the 
inflammations of the mucous surfaces in those diseases being transformed 
into the diphtheritic. In New York, scarlet fever beyond any other disease 
appears to furnish the conditions, which are most favorable for the occur- 
rence of diphtheria, and if these maladies are epidemic in the same locality, 
not a few of the scarlatinous patients are affected with diphtheria in 
the latter part of the first, or in the second week, though the converse 
seldom happens, that a patient with diphtheria contracts scarlet fever. 
The other infectious diseases, which are most liable to the diphtheritic 
complication, are measles, variola, whooping-cough, and typhoid fever, 
the bronchitis of these diseases changing to a pseudo-membranous inflam- 
mation. 

It is an interesting fact that in a patient suffering from diphtheria, the 
specific inflammation is apt to occur upon such surfaces as are already the 
seat of inflammation. A catarrhal inflammation however produced is 
liable, under the influence of the virus, to become diphtheritic and pseudo- 
membranous. Thus, if I recollect correctly, four children in the New 
York Foundling Asylum have had diphtheritic conjunctivitis, occurring 
upon trachoma, and Billroth remarks " catarrhal conjunctivitis, which is 
so very common, may become diphtheritic" {Surg. Pathol., translated, 
page 267). All who have seen much of diphtheria are familiar with in- 
stances in which a catarrhal inflammation, as from a burn, blister, or wound, 
as from tracheotomy, becomes diphtheritic. This general fact, in regard 
to the nature of diphtheria, and its mode of manifestation, namely, that 
in one affected by diphtheria, the diphtheritic inflammations appear by 
preference upon such surfaces as are already inflamed, has an important 
practical bearing. In a number of instances during epidemics of diph- 
theria, I have known careful and experienced physicians suppose that they 
were treating catarrhal inflammation of the air passages, when suddenly 



224 DIPHTHERIA. 

indubitable signs of diphtheritic disease occurred, usually with a fatal 
ending. They were obliged to confess to the friends of the patients that 
they had erred in diagnosis and prognosis, and their reputation was some- 
times seriously compromised. Now may there not, at least in a certain 
proportion of such cases, be an actual change of a non-specific catarrhal or 
may be croupous to a diphtheritic inflammation, such as occurs in the 
scarlatinous angina or rubeolous laryngitis in those who contract diph- 
theria ? 

The frequent occurrence of epidemics of diphtheria during the last 
twenty-five years, and the great mortality which has attended them, have 
awakened an interest in this malady which has led to a careful study of 
its causes and nature. Till recently these inquiries were entirely clinical, 
but, during the last few years, a new line of investigation has been fol- 
lowed, namely, that of experimenting on animals, the results being ob- 
served by the microscope; and while it has led to the confirmation of facts 
already ascertained, important discoveries have been made, and more 
important ones are probably in waiting. Among those who have taken 
the lead in this new field of investigation are Oertel, Buhl, and Hueter, 
of Germany. These microscopists, and several other experimenters of 
equal reputation who uphold their views, believe that they have dis- 
covered the cause of diphtheria, standing, as Oertel says, "on the very 
borders of the visible," with a high power of the microscope. 

This discovery is so important, not only in itself, but from the promise 
which it gives of the results of future research, and from the stimulus 
which it imparts to such inquiries, that a brief statement of the facts in 
reference to it cannot fail to be interesting at the present time, when diph- 
theria is so prevalent and fatal in this city and country. The minute 
objects which the observers alluded to have discovered in patients affected 
with diphtheria, and which, they suppose, cause the disease, are endued 
with life and motion. They belong to the class of microscopic vegetable 
parasites, which have been designated bacteria. The bacteria have been 
divided by Colin into four genera, with species ; but only two of these, it 
is thought, sustain a casual relation to diphtheria,- namely, the sphero- 
bacterium or spherical bacterium, or, as Oertel designates it, the micro- 
coccus; and secondly, though in less degree, because less numerous, though 
coexisting with the other form, and penetrating the tissues with it, the 
micro-bacterium, or rod-like bacterium. 

The microscope, in the hands of various observers, has revealed the fol- 
lowing important facts relative to diphtheria : In every tissue which is the 
seat of diphtheritic inflammation, and in every diphtheritic pseudo-mem- 
brane, the spherical bacteria occur in immense numbers, accompanied by 
a smaller number of the other kind. In severe cases, in which the system 
is infected, they occur also in the blood. Ordinarily, as the symptoms of 
diphtheria become more grave, a proportionate increase in the number of 



NATURE — CAUSES. 225 

spherical bacteria can be demonstrated by the microscope. They are found 
in the discharge from the edges of the wound produced by tracheotomy, 
performed in the treatment of diphtheritic laryngitis, and upon these 
edges they multiply rapidly, just before a pseudo-membrane forms. If, 
upon any surface, which is the seat of ordinary catarrhal inflammation, 
other vegetable organisms, as the leptothrix buccalis, or oidium albicans, 
are present — if diphtheritic inflammation supervene, these organisms 
diminish and disappear, as if deprived of the required nutriment, and are 
succeeded by the sphero- and micro-bacteria, which increase in numbers 
as the specific inflammation extends. On the other hand, when the diph- 
theritic inflammation abates, these bacteria disappear, and other vegetable 
forms may succeed. In the very commencement of diphtheria, the grayish- 
white spots which appear upon the inflamed surface consist entirely of 
these bacteria, with epithelial cells and mucus, while fibrin and pus appear 
at a later period, as a result of inflammatory reaction. 

These facts having been ascertained, various experiments were made by 
Oertel, Hueter, Von Trendelenburg, NasselofF, Eberth, and others, in 
order to determine more fully the exact relation of the sphero-bacteria 
and micro-bacteria to diphtheria. These organisms were not found in the 
croupous membrane, produced by the application of a powerful chemical 
agent, as ammonia, nor upon the inflamed surface underneath the mem- 
brane, " although the fibrous exudation afforded a soil which varied little 
or not at all in its histological and chemical composition from that induced 
by diphtheria." (Oertel.) The mucous membrane of the air passages, 
the cornea and muscles in animals, were inoculated with diphtheritic mat- 
ter, and these two kinds of bacteria were found to increase rapidly, pene- 
trating the tissues in a short time, and infecting the system. Oertel says : 
"I have noticed in numerous inoculations that if various bacteria, besides 
the micrococcus, as, for instance, bacillus, spirillum, and bacterium lineola, 
were present in the matter to be inoculated, only micrococci (sphero-bac- 
teria) and the bacterium termo (in its most minute forms accompanying 
them) showed evidence of prolific growth, while all the other forms disap- 
peared altogether." NasselofF and Eberth inoculated the cornea with 
diphtheritic matter, and found that the sphero-bacteria and micro-bacteria 
penetrated its layers, forcing them apart, and causing within a few days 
intense keratitis and the death of the animal by infection of its blood. 
" In the same way," says Oertel, " according to my experiments, the bac- 
teria spread over the mucous membrane of the trachea, beset the cellular 
elements, crowd especially into the young exudation cells, or are taken up 
by them, and gradually cause their dissolution ; they fill the blood- and 
lymph-vessels, and bring about, in a mechanical way, a damming up of 
the fluids, and, as a consequence, serous exudation. As they close up the 
capillary vessels, they occasion stagnation in the blood circulation, which 
induces disturbance of nutrition in the walls of the capillaries, and even 
15 



226 DIPHTHERIA. 

rupture of the same. Muscular fibres, also, which are covered and filled 
with colonies of micrococci, degenerate and slough ; in like manner, in 
severe cases, immense numbers of bacteria appear heaped up in the urinif- 
erous tubules and Malpighian corpuscles of the kidneys, and occasion 
there parenchymatous inflammation, capillary embolism of the glomeruli 
of the kidney, with ruptured vessels and formation of epithelial casts in 
the tubes. In the lymph and blood streams (compare also Hueter), in 
long-continued sickness of the animal experimented on, these bacteria 
also accumulate in masses. They induce, as exciters of decomposition and 
disorganization of organic nitrogenous bodies, septicaemia, through the 
vegetative process they undergo, and through their relation to oxygen." 

Finally, Erfurth repeatedly inoculated the cornea with a negative result, 
using for the purpose diphtheritic material from which the bacteria had 
been so far as possible separated. 

The importance of such experiments cannot be too highly estimated. In 
the opinion of those who have performed them, the conclusion is inevitable 
that diphtheria is produced by bacteria, which, coming in contact with the 
mucous membrane, or the cuticle deprived of its epidermic covering, ad- 
here to it ; and these, multiplying rapidly, burrow through the tissues, and, 
entering the vessels, infect the whole system. The reason assigned why 
diphtheritic inflammation in most cases appears primarily and chiefly upon 
the faucial and nasal surfaces is, that the air, which contains the germs of 
the bacteria, constantly passes over these surfaces, and, as regards the 
fauces, the ingesta also, which may contain them. The important practi- 
cal inference from this theory is, that diphtheria is entirely local in its 
commencement, and is amenable to local measures. 

These experiments, apparently so conclusive, and the brilliant results 
claimed for them, probably produce at first in most persons engaged in 
microscopical or pathological studies, a degree of enthusiasm in the belief 
that a new era is dawning in our knowledge of the contagious and mias- 
matic diseases. And since the German microscopists and pathologists are 
close and accurate observers, we accord to their researches and opinions a 
degree of credence which we are reluctant to yield to our own scientists 
who are engaged in similar studies. 

But the causes and nature of a disease cannot, in general, be fully 
elucidated by experiments alone, such as have been detailed. They should 
be aided or supplemented by clinical observations, and of these, as regards 
diphtheria, we have had an abundance in New York during the past fif- 
teen years. Clinical observations may modify or correct the theories 
derived from the results of experiments. 

Two distinct propositions are evidently included in the bacterian theory, 
to wit : that bacteria cause diphtheria, and secondly, that this disease is at 
first local, and that afterwards it becomes constitutional or general by the 
entrance of the specific principle into the blood. Whether diphtheria is 



NATURE — CAUSES. 227 

primarily local or primarily constitutional, or is in some at first local and 
in others at first constitutional, is of course a distinct proposition from that 
regarding the relation of bacteria to the malady ; and whatever the truth 
may be in reference to the one, does not affect the other. 

It is evident that the truth regarding the relation of bacteria to diph- 
theria is either that they are the specific principle, and therefore cause 
the disease, or that the cause is something more subtle, not yet discovered, 
which produces such deterioration of the tissues and blood, that they be- 
come a nidus, in which bacteria are early and rapidly developed. My own 
belief is more and more established, that the latter is the true theory, and 
that those who believe otherwise have mistaken an effect for the cause. 
As a deteriorated condition of the buccal surface and its secretions fur- 
nishes the nidus, in which the oidium albicans springs up, so, it seems 
to me not improbable, that those minute organisms found in and upon 
the tissues in the infectious diseases, as that seen by Letzerich in pertus- 
sis, and the bacteria in diphtheria, will yet be shown to be secondary pro- 
ductions., and not causative agents. From the very early appearance of 
bacteria in diphtheritic processes, we may believe that they sustain a close 
relation to the specific principle, and that this principle is even attached 
to them, so that they are agents of infection, and yet withhold our assent 
from the doctrine that they are, themselves, the specific principle, or that 
it proceeds from them. 

With an experienced microscopist of New York, I have examined the 
secretions and exudations upon the fauces in various cases of pharyngitis, 
both diphtheritic and non-diphtheritic, and we ordinarily found the 
micrococcus in abundance in the inflammatory product, whether diphthe- 
ritic or non-diphtheritic, a secretion or exudation, if it had remained some 
time upon the surface of the fauces. In one case of simple pharyngitis, 
no bacteria could be discovered on the first day in the secretion which lay 
in the depressions over the tonsils, while, on the second day, numerous 
micrococci had appeared. Micrococci, then, which are not distinguish- 
able with our present means of observation from those in a diphtheritic 
exudation, may occur in great numbers in the secretions of non-specific 
inflammations, so that their presence does not afford certain indication 
of the diphtheritic disease. It is also well known that bacteria, which 
seem to be identical with those in diphtheria, are frequently found upon 
the gums and between the teeth in health. Moreover, in the intervals of 
epidemics, and in localities where diphtheria has not occurred, or has oc- 
curred rarely, the microscope discloses the existence of bacteria, which 
resemble in form and activity those found in diphtheritic products, and 
in sufficient numbers to justify the belief that they frequently pass over 
the fauces in the inspired air. How remarkable, if the bacterian theory 
is true, that fungi, which, under ordinary circumstances, are innocuous, 
should exhibit the fearful energy and destructive power which we observe 



228 DIPHTHERIA. 

in diphtheria ! It has however been suggested to me, that the diphthe- 
ritic bacteria may possess peculiar functions and properties, since it is 
very difficult to observe differences which may exist and classify organisms 
which are "just on the borders of the visible." A fact which, till it is 
satisfactorily explained, must, I think, throw doubt on the bacterian 
theory, is that the bacteria do not irritate the lungs. If, during inspira- 
tion, they are carried along the current of air, and certain of them lodge 
upon the fauces, where they produce the specific inflammation, a larger 
number must enter the lungs, where we would suppose, from the delicate 
structure of these organs and their proneness to inflammation, they would 
produce severe results; so far from this occurring, bronchial and pulmo- 
nary catarrhs are rare at the commencement of diphtheria, and not common 
at any stage of the malady. 

Since the publication of the bacterian theory, I have made microscopic 
examinations of diphtheritic pseudo-membranes, in order to observe the 
form and movements of the micrococci, and the effect upon them of the 
medicinal substances which I have been in the habit of applying to the 
throat in diphtheria. With a magnifying power of 500 diameters, these 
parasites are seen as dancing or oscillating points, or rather as minute cells, 
shining or opaque, according to their distance from the eye. No one can, 
I think, observe their constant motion without admitting that they may, 
when in colonies, be irritants of the tissue with which they are in contact 
in the system, diverting nutrition and disturbing the function ; and with- 
out also believing, since they are so much smaller than the blood-cor- 
puscles, that multitudes of them may enter the circulation, since, in the 
deepest portion of the pseudo-membrane, they are in immediate relation 
with the capillaries and lymphatic vessels. It is not improbable, in view 
of these facts, that the spansemia of diphtheria is partly attributable to 
these organisms in the lymph and blood, for they could hardly exist in 
these liquids in any number without interfering seriously with the nutri- 
tive process. 

We may, therefore, believe that bacteria play a certain part in pro- 
ducing the diphtheritic cachexia, while we hold that the specific prin- 
ciple has probably thus far eluded the very thorough search instituted 
for its detection. Does not also the prevalence of inflammatory throat 
affections, some of which are very mild, during an epidemic of diphtheria, 
indicate an obscure meteorological cause of the disease quite distinct from 
the bacteria ? Moreover, does not that common sequel of diphtheria, 
namely, paralysis, indicate that there is something peculiar in the diph- 
theritic virus, that it is distinct in nature and action from the bacteria and 
from septic poison ? — for those who recover from septicemia, as it occurs in 
surgical and other cases, and in which disease bacteria are abundantly 
developed in the blood, have no special liability to paralysis. Another 
fact, indicating a cause distinct from the bacteria, but a cause acting pro- 



NATURE — CAUSES. 229 

bably in the same manner as that of scarlet fever and measles, is the long 
incubative period in certain cases, as we have seen above. Fungi visible 
under the microscope, and multiplying with great rapidity, would not pro- 
bably remain a whole week in or upon the tissues without producing the 
least symptom, and then suddenly produce a dangerous disease. 

If the views expressed above be correct, it seems probable that diphtheria 
is a constitutional disease from its inception. With sufficient observation of 
cases, and careful examination of the clinical history, facts appear which, 
I think, will lead most observers to this conclusion. The importance of 
the subject will justify the following statement of some of these facts. 

1. It is a law in pathology that those diseases which have or may 
have a long incubative period — say of a week or more — are constitu- 
tional. 

2. Another fact, which indicates primary blood poisoning in diphtheria, 
is observed in certain cases, namely, the occurrence of severe constitutional 
symptoms for a longer or shorter time, perhaps for half a day, before the 
appearance of the usual inflammation. Thus a girl of five years, having 
malignant diphtheria, whom I saw in consultation, was carefully exam- 
ined on the first day of her sickness by the attending physician, and, 
although he closely inspected the fauces, there was no appearance which 
indicated the nature of the malady till the subsequent day. In such 
cases, a sufficient number of which I have observed, there is apt to be 
complaint of soreness of the throat, or difficulty in swallowing, almost from 
the beginning of the general symptoms ; but the pain and tenderness seem 
to be in the deeper tissues of the neck, and the fact that redness of the 
mucous surface does not appear till some hours subsequently, is evidence 
that the inflammation is developed from within, and not from the irritating 
effect of the poison upon the surface. 

Again, treatment of the inflammations by the most reliable and efficient 
antiseptics and disinfectants which we possess, commenced at the earliest 
possible moment and repeated at short intervals, does not prevent the 
occurrence of indubitable symptoms of blood poisoning in cases of a severe 
type. Thus I have treated every portion of the inflamed surface, as far 
as it was accessible, every second or third hour, with carbolic acid and 
other disinfectants, almost from the very commencement of diphtheria, 
and so thoroughly that any vegetable or animal poison, with which the 
remedies had come in contact, would probably have been destroyed, or 
rendered inert, and yet, except in mild cases, symptoms of diphtheritic 
blood poisoning have occurred, and as early and uniformly as if less ener- 
getic local measures had been employed. While, therefore, I do not fail 
to recommend local treatment as calculated to diminish septic poisoning, 
and relieve the inflammations, I have lost confidence in it as a means of 
preventing the entrance of the diphtheritic poison into the blood. Its 
powerlessness to prevent contamination of the blood by the diphtheritic 



230 DIPHTHERIA. 

virus is an additional evidence that this contamination occurs indepen- 
dently of the local disease, and probably precedes it. 

3. The quick succumbing of the system in certain malignant cases is 
evidently due to diphtheritic toxaemia. We sometimes observe a fatal 
result on the second, third, or fourth day, without any dyspnoea, or suffi- 
cient laryngitis to compromise life. Cases of this kind, terminating 
fatally even in the first day, have been reported. The system is suddenly 
overpowered by the poison, struck down, as it were, by the profound 
blood change, Avhile the inflammations are still in their incipiency. 

4. Important evidence of the constitutional nature of diphtheria is 
afforded also by the state of the kidneys. No internal organs are so often 
affected in diphtheria as the kidneys, and on account of their location and 
anatomical relation, it is evident that the poison first passes through the 
system before it reaches them. Any clinical or anatomical fact, there- 
fore, which indicates that the diphtheritic virus has reached and affected 
the kidneys, affords proof that it has penetrated the system, and poisoned 
the blood. Now the occurrence of albumen, with granular or hyaline 
casts, in the urine, in cases unattended by dyspnoea, affords proof of 
nephritis, caused by the action of the poison on the kidneys. 

Sir John Rose Cormack, of Paris, in a series of interesting and useful 
papers relating to diphtheria, published in the Edinburgh Medical Journal 
during 1876, states that albuminuria, and of course the nephritis on which 
it depends, sometimes begin as early as the first day. My observations 
confirm this statement, as in the following cases : — 

Case I L. McD., aged three years, was first visited by me on Feb- 
ruary 29, 1876. I learned from the parents that she had been feverish 
during the preceding forty-eight hours, and her urine very scanty. A 
moment's examination was sufficient to show that the case was one of 
malignant diphtheria, for the fauces were already nearly covered by the 
diphtheritic pellicle, the temperature was 103^°, and the pulse 140. The 
skin was hot and dry, and there was moderate swelling under the ears, 
and a muco-purulent discharge from the nostrils. On account of the 
scantiness of the urine, the amount not exceeding f giv-v daily, it was 
impossible to obtain sufficient for examination till the following day. It 
was then found to have a specific gravity of 1032, to contain a deposit of 
urates and hyaline and granular casts, a diminished amount of urea, and a 
large quantity of albumen. It can hardly be doubted from the scantiness 
of the urine, and the large amount of albumen found when the urine was 
first examined, that albuminuria had been present on the first day. 

Case II The following w r as a similar case : K., aged four years, 

living in West Thirty-sixth Street, was visited by me in consultation on 
Jan. 29, 1875. Her sickness had also continued forty-eight hours ; her 
fauces were swollen, and covered with the diphtheritic pellicle, which was 
dark and offensive ; respiration guttural; pulse 120; temp. 101°; she 
had a free discharge from each nostril ; urine scanty, its specific gravity 
1030 ; it contained a small amount of albumen, with casts, and a large 
amount of urates, with no apparent diminution of the urea. Death oc- 
curred on the fourth day. 



NATURE — CAUSES. 231 

In such severe cases, in which albumen and casts are found in the 
urine at the first visit of the physician, there can be little doubt that the 
nephritis begins nearly or quite as early as the pharyngitis, and therefore, 
since poisoning of the blood must antedate the renal disease, diphtheria is 
in these cases very early, probably from the occurrence of the first symp- 
toms, a constitutional malady. 

Again there are cases, though not frequent — three I can recall to mind 
during the last two years in my practice — in which the external manifes- 
tations of diphtheria are very mild, even insignificant, and quickly cured, 
but in which the kidneys are severely affected. The occurrence of such 
cases is best explained on the supposition that the first departure from the 
state of health is in the blood, and that the blood change gives rise to the 
inflammation of the mucous membrane externally, and of the kidneys 
internally, rather than upon the supposition that the transient and insig- 
nificant inflammation of the mucous membrane is the first event in the 
series of morbid changes, and that this inflammation leads to poisoning of 
the blood, and the establishment of a much more severe and protracted 
inflammation in the kidneys. The following are histories of the cases 
alluded to : — 

The house 229 West Nineteenth Street, New York, is an old wooden 
structure, and the family, which has occupied it during the last five years, 
has been three times visited by diphtheria, the first case, that of the 
oldest child, proving fatal. In February, 1876, one of the children had 
diphtheria in a moderately severe form. He recovered, and, after my 
visits had been discontinued, his sister, aged six years, who had had scar- 
let fever when eighteen months old, became feverish, and complained of 
her throat. No rash appeared on her skin, and there was apparently no 
coryza. Inspection of the fauces by the parents revealed a small diph- 
theritic patch over each tonsil. Although diphtheria was so frightful a 
malady to this family from their past experience, the case seemed so mild 
that the parents treated it without medical attendance, by the remedies 
which had been employed for the boy. A mixture of carbolic acid, sub- 
sulphate of iron, and glycerine, was applied to the fauces every third hour, 
sufficiently often, apparently, to destroy all bacteria or other vegetable or 
animal organisms with which it might have come in contact, and within 
two or three days the inflammation of the throat seemed to the parents to 
be cured. Nevertheless, with this insignificant inflammation of the fauces, 
so quickly subdued, and with no other apparent inflammation of the mu- 
cous surfaces, there was severe internal disease goino- on as the result of 
the general infection. The child did not regain her former appetite ; she 
had increasing pallor, although able to play about the house ; and, finally, 
in the third week, when I was called to see her, slight oedema of the face 
and limbs was observed. Her urine, which was scanty, was found to 
contain pus and blood corpuscles, albumen, and granular casts, and nearly 
two months elapsed before, under treatment, it became normal, and her 
health was restored. 

The second case occurred in January, 1878, in West Fifty-first Street. 
A boy, aged six years, in a family in which diphtheria was occurring, had 
slight sore-throat, which abated in two or three days. It was attended 



232 DIPHTHERIA. 

by little or no exudation, and would not have been considered diphtheritic, 
except for the circumstances in which it occurred, and the subsequent 
history. Still, the boy remained ill, and fretful, and four days subse- 
quently his urine was found to be very scanty and very albuminous ; and 
three days later death occurred, preceded by total suppression of urine. 
The last urine passed, which was not more than a teaspoonful, became 
nearly semi-solid by heat. There had been no scarlet fever in the 
family. 

The above facts indicate, in my opinion, the constitutional nature of 
diphtheria; but within the last few years the old doctrine that diphtheria 
is local in its commencement, and is, therefore, at least in many instances, 
amenable to local treatment early applied, has been so revived, and pro- 
moted by the advocates of the bacterian theory that it has had a marked 
influence upon the treatment. It does, indeed, sometimes seem as if mild 
cases, which may apparently fully recover in two or three days, with only 
local measures, could not be attended by systemic infection ; but we ob- 
serve the same mildness, though less frequently, in scarlet fever. And 
not infrequently, even in the mildest cases, the constitutional nature of 
diphtheria is shown by the return, and return more than once, of the 
pseudo-membrane after it has been fully removed by local treatment. 
The persistence of the inflammation, and of its peculiar exudative nature, 
corresponds more with the history of those phlegmasia which proceed from 
the state of the blood, than of those which are merely local. 

Diphtheria, as experiments on animals and the histories of many re- 
ported cases show, is sometimes communicated by inoculation. Most 
frequently, however, the virus is received from an infected atmosphere. 
The anti-hygienic conditions in which it originates are well known. 
Many cases in New York are traced to sewer gases, which have escaped 
into houses through imperfect plumbing. 

When diphtheria reappeared in New York in 1858, after an absence of 
more than fifty years, some of the first and most severe cases seen by my- 
self occurred in the upper part of the city, along the old water-courses, 
where in consequence of street grading, water was stagnant and impreg- 
nated with decaying animal and vegetable matter. Though observing 
and treating diphtheria, both in its epidemic and sporadic form, during 
the last twenty years, I have not observed an instance in which it seemed 
to be communicated from house to house by the clothing, as we frequently 
observe in cases of scarlet fever, and sometimes of measles. When it 
spreads from house to house, or even from room to room, in the same 
house, I think that it is almost always by the visits of persons having 
diphtheritic inflammation. The area of contagiousness of diphtheria is 
therefore limited to the room in which the patient resides, or to his imme- 
diate vicinity. 

But it is well known that the sputum of a diphtheritic patient and bits 
of diphtheritic pseudo-membrane may communicate diphtheria. The ex- 



ANATOMICAL CHARACTERS. 233 

periments indeed show this, as do many observations published in the 
records of diphtheria. Therefore, caution is required that children be not 
needlessly exposed to the handkerchiefs or towels employed by a patient, 
nor to his breath, especially during the act of coughing. We may here 
repeat that in localities where diphtheria is endemic or epidemic, certain 
constitutional diseases sustain a causative relation to diphtheria. Thus 
scarlet fever furnishes the conditions in which diphtheria arises in a house 
whose sanitary state is apparently good, and when there has apparently 
been no exposure to a diphtheritic patient. And in three instances I have 
known diphtheria thus originating to become dissociated from scarlet 
fever, and spread as a primary and independent malady. 

Anatomical Characters In the commencement of diphtheria we 

observe redness of some portion of the mucous surface. In most cases it 
is the faucial membrane which is first affected, and that part of it which 
covers the tonsils. If there is a pre-existing inflammation of one of the 
other mucous surfaces, or a portion of the cuticle denuded of its epidermis 
and inflamed, the specific inflammation is apt to appear primarily upon 
these parts, with or without its simultaneous appearance upon the faucial 
surface. 

The inflammation varies greatly in severity and extent. In a mild 
attack it is often limited to a part of the fauces, and there are few excep- 
tions to the rule that the tonsillar portion is affected, the redness gradually 
fading away in the healthy membrane beyond. In all except the mildest 
cases, the whole faucial surface is, in the course of a few hours, involved 
in the inflammatory process, its mucous membrane is thickened and soft- 
ened, and its follicles tumefied, and actively secreting. In severe cases 
the uvula is elongated and enlarged from watery infiltration ; the sub- 
mucous connective tissue also becomes involved to a greater or less extent, 
and swells; and the submucous lymphatic glands, especially the tonsils, 
also swell, and are painful. The color of the inflamed surface is some- 
times a deep, bright red, almost like arterial blood ; in other cases it is a 
dusky red, which indicates a vitiated state of the blood. The dusky red 
hue is more common in secondary than in primary diphtheria ; it is also 
common in the obstructive laryngitis of diphtheria, the color becoming 
more and more dusky as the obstruction increases. 

Within a day, and usually within a few hours, from the commencement 
of the inflammation, a small slightly raised patch or spot is observed 
usually upon the tonsillar portion of the inflamed surface, of little import- 
ance, did the disease stop here, but very significant as a diagnostic sign, 
and as a forerunner of what is to happen. This patch, termed the pseudo- 
membrane, gradually becomes firmer, and at the same time thicker and 
broader from fresh exudations underneath, and it has a grayish or grayish- 
white color. Sometimes different points or patches are observed, which 
extend and coalesce so that the fauces are almost entirely concealed from 



234 DIPHTHERIA. 

view. The pseudo-membrane is closely attached to the mucous surface, 
which it penetrates, becoming firm, and not easily detached. Attempts 
to separate it often lacerate the engorged capillaries, producing a free flow 
of blood. It does not ordinarily attain a greater thickness than one- 
eighth to one-sixth of an inch. I have seen it, however, not far from 
one-third of an inch thick. By the microscope we observe numerous 
micrococci with a small number of rod-like bacteria in the meshes of the 
exudation. They can be traced through the subepithelial tissues, being 
adherent to and even incorporated in pus-cells, and entering into and 
blocking up the minute lymphatics and bloodvessels. 

The same pseudo-membrane is often firmer in one part than another, the 
outer and central portions being more compact and tough for a time than 
that underneath, which is more recent, and in which there is less fibrilla- 
tion. After a few days, however, decomposition commences, and then that 
which was first formed becomes softer than the more recent production. 
When this occurs, the color of the exudation changes from a whitish or a 
grayish-white to a dirty brown, and its exposed surface is uneven and 
jagged from the partial separation of shreds and fibres. 

The escape of the liquor sanguinis from the engorged vessels diminishes 
somewhat the turgescence of the inflamed tissue. If this is considerable, 
the pseudo-membrane often sinks to the level of the surrounding sur- 
face, producing an appearance very much like that of an ulcer, or even of 
gangrene. Though there is no loss of substance in this stage of the pseudo- 
membrane, it does, however, often occur, being produced by the presence 
and contraction of the fibrin with which the mucous membrane is infil- 
trated. Sometimes the pseudo-membrane has a reddish tinge. This is 
due to rupture of the capillaries, and the escape of the blood-corpuscles. 
It occurs in those cases in which the inflammation is intense, and the ca- 
pillaries are greatly engorged. Sometimes the lower part of the exudation 
is blood-stained, while the exposed surface has the usual grayish-white 
hue. For a very interesting and instructive description of the anatomical 
characters of the diphtheritic pseudo-membrane, the reader is referred to 
the treatise of Prof. Rindfleisch, of Bonn, relating to pathological his- 
tology. His description is as follows :— 

" Genuine diphtheritis has no claim to be regarded as a specific process 
in the same measure as croup. That which microscopically characterizes 
it, and has become the occasion of placing it as a membranous inflamma- 
tion is the formation of a whitish-gray, compact, felted membrane, which 
is elevated, perhaps, to the height of one-half line along the level of the 
mucous membrane, but penetrates just as deep into the substance of the 
mucous membrane, and is most intimately connected with the latter. This 
membrane is nothing that is superimposed, nothing secreted, but the mu- 
cosa itself, as far as it has been partly tumefied, partly rendered anaemic, 
even by the excessive infiltration with cells. This condition has not im- 



ANATOMICAL CHARACTERS. 235 

properly been compared with a mortification by a chemical agent, with a 
corrosion, and the diphtheritic membrane has been designated as diph- 
theritic scab ; in fact the diphtheritic membrane is a caput mortuum, it 
can undergo no other changes than those of putrefaction, of decomposition ; 
and the question only is, how it is loosened and removed from the inti- 
mate organic connection in which it stands with the mucous membrane. 
A sharply defined boundary line separates, as we can convince ourselves 
with the naked eye, the living from the dead ; but numerous connective- 
tissue fibres, bloodvessels, nerves, and elastic fibres, pass over from the 
living into the dead ; they must all have separated ere the loosening can 
proceed. The means which are placed at the command of the organism 
are inflammation and suppuration. We call this inflammation ' reactive,' 
and unite with it the idea as though this were an answer to the irritation, 
which the diphtheritic scab exerts upon the surrounding mucous mem- 
brane ; yet a portion of the hyperemia also may be explained according 
to static principles as collateral fluxion. The pus collects between the 
scab and the healthy parts and always, accordingly as the fibrous bridges 
mentioned melt down and tear, the separation begins now at the edges, 
then at the centre. After it is completed an ulcer remains behind which 
.? is disposed to rapid cicatrization ; not unfrequently, however, the process 
repeats itself again at the same place ; we have a new scab, and with it 
anew the necessity of a purulent separation, after whose termination a 
very considerable loss of substance remains. The cicatrices finally result- 
ing distinguish themselves by their capacity of vigorous retraction, so that 
the danger of subsequent contraction of mucous membrane canals, espe- 
cially of the large intestine after dysentery, threatens so much the more, 
the more diffused the ulceration was." [Text-book of Pathological His- 
tology, translated, page 354.) 

Two of the microscopists of New York who, for years, have been en- 
gaged in microscopical and pathological studies, kindly consented to ex- 
amine for me the anatomical characters in the following cases. The 
examinations in the first, second, and fourth cases were by Dr. Suther- 
thwaite ; in the third by Dr. Heitzman, formerly clinical assistant to Prof. 
Rokitansky, in Vienna. The specimens were placed in a solution of 
bichromate of potassium immediately after their removal from the bodies : — 

Case I. — H , aged four years, and two brothers S., who lived di- 
rectly opposite in the same street in New York, were daily playmates. 

On January 27, 1876, H became feverish and complained of sore 

throat, and four days subsequently died of malignant diphtheria. This 
case was carefully examined by me in consultation, and minute records of 
it preserved. Before it terminated, the two brothers S. became affected 
with diphtheritic laryngitis. The younger brother, aged three years, was 
for a time in a very critical state from the dyspnoea, but recovered in about 
one week. The older brother, aged six years, died, having the following 
history: On January 29, two days after the commencement of diphtheria 



236 DIPHTHERIA. 

in his playmate, H , he vomited and became feverish, and his voice 

hoarse. These symptoms continuing, I was asked to visit him on Febru- 
ary 2. His respiration at this time was harsh, and audible in the adjoin- 
ing room, and the cough croupy ; pulse 96; temperature in axilla 100°; 
he takes considerable nutriment, and sits quietly, or walks about the room ; 
fauces red, and sliglitly swollen, but without any diphtheritic exudation 
upon their surface ; has slight glandular swelling underneath the ears ; the 
urine contains no albumen, and the nitric acid test shows no excess of 
urea. The constant inhalation of the spray of lime-water is recommended, 
with the use of tonics. Feb. 4. Pulse 96, temperature 99° ; breathes with 
much difficulty at times, but there is still no pseudo-membrane upon the 
fauces ; has expectorated since the last record two thick pieces of pseudo- 
membrane, each about one inch in length, apparently from the larynx ; 
specific gravity of urine 1022 ; it contains a deposit of urates, but no albu- 
men ; urea apparently somewhat in excess of the normal quantity. Feb. 
5. Pulse 92 ; temperature 101 j° ; has a small diphtheritic patch, not more 
than three lines in diameter, over the left tonsil. Feb. 6. The pellicle 
upon the tonsils has disappeared ; the urine for the first time albuminous, 
thirty-six hours before death ; its specific gravity 1024; temperature 103° ; 
dyspnoea great ; pulse about 120. Death occurred on Feb. 7. 

Sectio Cadaveris, 19 hours after death ; body spare, but not emaciated; 
rigor mortis present ; has post-mortem extravasation of blood along the 
back, and a thin blood-stained fluid escapes from the mouth ; two or three 
drachms of transparent liquid in the pericardial sac ; a large yellowish- 
white clot fills the right ventricle, and is prolonged into the pulmonary 
artery ; the right auricle also contains a large clot, soft and dark in its 
centre, but firmer and of a whiter color externally ; left ventricle contains 
a few soft dark clots, with a little fluid blood; left auricle partly filled with 
blood of a tarry appearance ; tonsils not enlarged, but soft, and a yellowish 
diffluent secretion lies in the depressions on their surface ; subcutaneous 
glands of the neck slightly enlarged, one being somewhat larger than a 
filbert ; under surface of epiglottis, and entire surface of larynx, covered 
by a firmly adherent pseudo-membrane which entirely conceals from view 
the vocal cords and the sinuses of Morgagni ; the pseudo-membrane is 
continued over the surface of the trachea, being less adherent than in the 
larynx, and, near the bifurcation, it floats freely ; it does not extend into 
the bronchus or bronchial tubes of the left lung, and this lung is normal. 
In the right lung the pseudo-membrane extends as far as the bronchial 
tubes of the third order ; the upper lobe of the right lung is in the second 
stage of pneumonia, its cut surface being rough and granular, and liquid 
escaping from it on pressure ; the right, middle, and lower lobes are con- 
gested, and in the lower lobe is a single hepatized nodule ; those portions 
of the bronchial tubes which are not covered by the false membrane ex- 
hibit the appearance of catarrhal bronchitis. The liver is large, and not 
fatty ; spleen small, moderately firm, and contracted (this is noteworthy, 
as the spleen has been found large and soft in diphtheria) ; kidneys con- 
gested and swollen, and a stellate appearance of the vessels under their 
capsules ; surface of both small and large intestines congested. 

Microscopic Examination Red corpuscles of the blood well-preserved, 

some of them round, others crenated, and all granular ; large masses of 
transparent material, containing red corpuscles, floated in the blood. The 
rod and chain forms of bacteria were observed in the blood, but not in 
greater number than are often seen in other blood the same number of 



ANATOMICAL CHARACTERS. 237 

hours after death. (A few grains of chloral had been added to this spe- 
cimen of blood immediately after its removal.) Substance of heart appa- 
rently normal, showing no fatty degeneration, nor infiltration ; no bacteria 
can be recognized in the substance of the heart. Kidneys : Right kidney 
examined ; Malpighian bodies congested, and extravasations of blood 
throughout this organ ; tubal epithelium granular ; increase of connective 
tissue in points near periphery of kidney, showing insterstitial nephritis, 
but no increase observed in this tissue in other parts of the organ ; no 
bacteria that could be certainly recognized as such in the kidney. Spleen : 
Multitudes of granules in scrapings from the cut surface of this organ, 
many of them so small as to be with difficulty recognized with a magnify- 
ing power of over 600 diameters ; some of them gave the appearance of 
the usual forms of bacteria. 

Larynx : Thickness of false membrane which covered the entire surface 
of this organ varied from t -J-q to -j> 6 of an inch ; thickness of mucous mem- 
brane about z \ of an inch ; epithelial border of mucous membrane could 
be traced inwards ^ ho t° tp °f an mc h> where it became indistinct, merg- 
ing into the other tissues which were more or less infiltrated with embryonic 
cells and blood. The false membrane consisted of a network of a homo- 
geneous material, most of the meshes being empty, but those nearest the 
epithelial layer containing more or fewer epithelial cells. The boundary 
line between the false membrane and the mucous surface could not be dis- 
tinguished by the microscope in many of the sections, the network of the 
pseudo-membrane extending into the mucous membrane. But in other 
places the line of separation could be distinguished, and here and there 
the pseudo-membrane and mucous surface were separated by collections of 
embryonic cells. The lymph follicles and racemose glands were appa- 
rently normal ; mucous surface infiltrated with granular matter and red 
blood-corpuscles ; cylindrical epithelial cells, some of them with cilia, were 
distinctly visible both along the free border, and in the under surface of 
the pseudo-membrane. Trachea : The false membrane measures from 
about t 1q to 3L of an inch in thickness ; the mucous membrane -g 1 ^ of an 
inch, and its epithelial layer t Aq of an inch ; the epithelial cells are much 
more distinctly visible than in the larynx, an! the line of separation of the 
adventitious layer and the mucous surface is everywhere distinctly seen 
under the microscope ; the false membrane has the same general appear- 
ance as in the larynx ; but the mucous membrane is in a better preserved 
state than that of the larynx ; it is nevertheless infiltrated with granular 
matter, plastic matter, and red blood-corpuscles ; lymph follicles and race- 
mose glands apparently normal ; in the trachea, as in the larynx, a large 
number of embryonic or lymphoid cells — most of them no doubt becoming 
pus cells — lay between the false membrane and the mucous surface. 

Case II. — A second case, having the following history, occurred in the 
New York Eoundling Asylum in New York. George, aged two years and 
seven months, was under treatment for a second attack of measles, the 
eruption appearing on March 23, 1876. On March 24, the pulse was 136 
and temperature 104^°. The fauces presented a deep-red appearance, 
indicating severe pharyngitis, but without any membranous exudation. 
March 25. Pulse 140; temperature 103^° ; the rubeolar eruption is very 
thick over the entire surface. The Sister who has charge of the ward, 
noticing unusual ofFensiveness of the breath, has inspected the fauces and 
found on them the diphtheritic pellicle. March 26. Cough becoming 



238 DIPHTHERIA. 

croupy, and voice hoarse ; pulse 152, temperature 105^°. From this date 
the dyspnoea progressively increased, and death occurred on March 30. 

Sectio Cadaveris. — A considerable part of the interior of the larynx is 
coated with the diphtheritic pseudo-membrane, which is firmly attached to 
the mucous surface ; it extends without interruption over the larynx, and 
perhaps over one-third to one-half of the tracheal surface. It is not at- 
tached to this surface, but hangs over it like a curtain, suspended from its 
attachment in the larynx. Further down in the air passages there is the 
usual catarrhal inflammation of the mucous surface. 

Microscopic Examination — Larynx: The false membrane is found to 
consist of a network, apparently fibrinous ; in places, in the larynx, it is 
raised from the mucous membrane by an accumulation of embryonic or 
lymphoid cells underneath ; in other places it is adherent to the mucous 
membrane, but with a line of attachment which can be distinctly made out 
with the microscope ; while in other places still the network extends down 
into the mucous membrane, and no distinct line of separation can be seen. 
In the upper or exposed portion of the false membrane, no embryonic or 
lymphoid corpuscles are observed, but they are abundant in the deeper 
portion, and they infiltrate the whole mucous membrane extensively; upon 
the mucous surface, wherever the pseudo-membrane is detached, these cor- 
puscles are abundant ; in parts of the false membrane they fill so com- 
pletely the interstices of the network that epithelial cells can scarcely be 
distinguished within them ; in places, in the sections examined, the epithe- 
lium seemed to be wholly replaced by granular matter ; in general, the 
border line between the diphtheritic membrane and the mucous surface is 
marked by a somewhat denser exudation of the albuminate — a fibrinous 
appearing material — than is seen in the false membrane generally ; the 
bloodvessels in the mucous membrane of the larynx are numerous, and dis- 
tended with blood. Trachea : The epithelium, consisting of from two to 
three layers, is seen to be intact wherever it is observed ; the surface of 
the epithelium is covered with minute markings, probably the cilia in con- 
traction ; the pseudo-membrane is not seen to be reticulated as* in the 
larynx, perhaps from the contractions which had occurred in it ; it ap- 
peared granular and fibrous, and contained but few corpuscles. Lungs : 
A portion of one lung was found hepatized, and the alveoli of this portion 
contained pus cells, epithelial cells, blood, and a fibrinous appearing mate- 
rial (croupous pneumonia). Kidneys : The changes observed in these 
organs were those of tubal nephritis ; the tubes were highly granular, both 
in the pyramids and cortex ; no increase in the interstitial connective tissue 
was noticed ; in places the tubes were not granular. The muscular tissue 
of the heart seemed normal. 

Case III J , aged four years, an inmate of the N. Y. Foundling 

Asylum, began to have sore-throat on March 4, 1876. The fauces were 
red and somewhat swollen, but without any membranous exudation, and 
the diphtheritic nature of the disease was not at first suspected. My atten- 
tion was first called to this case on March 11, on account of almost total 
suppression of urine. The fauces were still injected, and somewhat swollen 
from catarrhal inflammation ; there was a copious muco-purulent discharge 
from the nostrils ; pulse 148. March 13. Pulse 144; temperature 101 J°; 
urine still nearly suppressed, though one drachm of infusion of digitalis is 
administered every fourth hour, and bromide of potassium, four grains, 
every second or third hour, for the restlessness. Dr. Reid, in using the 
catheter, observed a diphtheritic patch on the vulva ; there is moderate 



ANATOMICAL CHARACTERS. 239 

tumefaction under the ears ; the patient vomits often during the last days ; 
she has livid spots, from extravasation, under the skin ; and vision is much 
impaired, if not lost ; it is impossible to obtain any urine for examination. 
Death occurred without convulsions on March 15. 

Microscopic Examination of the Kidneys — The tubuli contorti of the 
first and second order of the cortical substance of the kidney almost all 
enlarged ; their epithelium swollen in many places to such a degree that 
no calibre of the tubules can be seen ; the epithelium richly provided with 
coarse granules, the enlarged living matter ; the original cement substance 
missing ; instead of this, new transparent lines formed within the proto- 
plasm, indicating the earliest stage of catarrhal inflammation, with parti- 
tion and new formation of epithelial elements ; the same changes, though 
in a less marked degree, observable in the epithelium of the straight ducts 
of the pyramidal substance, while the flat epithelial bodies of the narrow 
ducts appear almost unchanged. The connective tissue between the ducts 
and the enlarged glomeruli is somewhat increased in size, and it contains 
newly-formed nuclei in moderate number, with enlarged bloodvessels, some 
of which are much distended with blood-corpuscles ; no fatty degeneration 
in kidneys. In a few places, accumulations of dark granules occur within 
the ducts and their epithelium. These granules, not being united with 
each other by threads, nor staining with carmine, are considered to be 
micrococci, such as occur in any decomposing animal tissue. Whether 
they were present during the life of the patient, or were due to early cada- 
veric putrefaction (which is common after death from diphtheria), is un- 
certain. But since I have seen micrococci and bacteria in the fresh urine 
of children suffering from diphtheria, I would not deny the possibility of 
the occurrence of micrococci in the uriniferous tubules during life ; nay, 
even, they may produce the inflammatory process in a way still unknown 
to us. In the case under consideration no trace of casts was found within 
the tubules, so that the inflammatory process doubtless was not a croupous 
one, but a relatively slight process, termed catarrhal or interstitial ne- 
phritis. 

Case IV — M., aged four years, inmate of the N. Y. Foundling Asy- 
lum, New York, began to be sick May 6, 1876 ; was languid and feverish, 
temperature 104°, had redness of fauces and an exudation over each tonsil, 
nocoryza; evening temperature 103°. May 7. Pulse 120 ; temperature 
100°. May 8. Pulse and temperature as yesterday; urine scanty; no 
albuminuria, and no discharge from nostrils : the membrane extends from 
the sides of the throat to the roof of the mouth ; specific gravity of urine 
1021, urine contains no albumen, no excess of urea, and no deposit of 
urates. May 10. Pulse 140; has considerable oedema of fauces, and 
breathing guttural in sleep; vomited once since yesterday ; the urine con- 
tains for the first time a moderate amount of albumen, with hyaline casts; 
specific gravity 1018, acid; no urea deposited on adding nitric acid ; that 
alarming symptom in diphtheria, epistaxis, has occurred to-day. The 
records which were written daily till death, which occurred on the 14th, 
show a gradual increase of albumen with hyaline casts in the urine, in- 
creasing scantiness of urine, so that on the 13th not more than half an 
ounce was passed in twelve hours ; temperature not rising above 100^°, 
nor pulse above 108 ; poor appetite, occasional vomiting, and epistaxis. 
Death occurred from feebleness and blood-poisoning, notwithstanding that, 
from the first day, three grains of salicylic acid were given the first hour, 
two grains of quinine the second hour, and tincture of iron and chlorate 



240 DIPHTHEKIA. 

of potassa the third hour, these doses having been continued night and day 
in alternation ; with the application of carbolic acid and subsulphate of 
iron to the fauces, three times daily ; with nutritious diet, and the mode- 
rate use of stimulants. There were no symptoms referable to the larynx, 
unless a slight cough. 

Sectio Cadaveris. — Mucous membrane of larynx, trachea, and bronchial 
tubes intensely and uniformly injected, but without any membranous exu- 
dation ; lungs fully inflated, as if from commencing vesicular emphysema, 
and pale in front ; numerous extravasations of blood in the substance of 
the lungs and other organs ; the hemorrhages in and under the mucous 
membrane of stomach so abundant that the gastric surface presented a 
mottled appearance like the skin in measles : 

Microscopic Examination — The mucous membrane of the larynx and 
trachea was hyperaemic, but was otherwise apparently normal ; muscular 
tissue of heart normal ; spleen soft, but not appreciably enlarged. The 
scrapings of the cut surface of this organ contained red blood-corpuscles ; 
bodies from two to five times the size of the blood-corpuscles, holding in 
their interior oil-drops and fine granules, and having a yellowish-red color; 
granular lymphoid corpuscles, and granular debris. The walls of the 
stomach were congested, but without any noticeable exudation upon the 
surface ; the extravasations of blood, described above, were found to be 
chiefly in the submucous tissue. In some places the gastric tubes were 
bare, but in other places covered with amorphous matter ; but whether the 
covering substance was altered epithelium or diphtheritic exudation was 
not determined. The epithelium covering the more exposed portions of 
the tubes was in many places not distinct, while that covering the deeper 
portions of the tubes w'as clearly defined ; at the pylorus, upon the valve, 
the mucous membrane was deficient ; those portions of the true peptic 
glands lying below the tubes were normal. The mucous membrane in the 
lower part of the ileum was congested. Peyer's patches, and the solitary 
glands, both in the ileum and large intestines, were prominent, and sur- 
rounded by halos or rings of inflammation. Both the cortical and pyra- 
midal tubes of the kidneys contained granular epithelium. 

Briefly stated, therefore, the exudation of diphtheria is found to consist 
of fibrin forming a delicate interlacing network, epithelial cells more or less 
altered by the inflammatory process, leucocytes, nuclei, mucus, and amor- 
phous matter. Upon the faucial, buccal, laryngeal, and perhaps also nasal 
surfaces, the pseudo-membrane penetrates the entire mucous membrane, 
so that no line of demarcation between them can be seen with the micro- 
scope. Below the larynx upon the surface of the trachea and bronchial 
tubes, a distinct line of demarcation exists, as in the croupous exudation, 
so that the tracheal and bronchial pseudo-membrane can be readily de- 
tached, without impairing the integrity of the underlying mucous surface. 

The inflamed mucous membrane is not only hyperagmic and infiltrated 
with serum, but it contains numerous round white corpuscles (leucocytes) 
which may result in part from proliferation of connective tissue corpuscles, 
but are believed by most pathologists, since Cohnheim's well-known dis- 
covery, to be in great part wandering white corpuscles of the blood, which 
have escaped through the walls of the bloodvessels along with the fibrin. 



ANATOMICAL CHARACTERS. 241 

In the commencement of the diphtheritic inflammation, before the pseudo- 
membrane forms, we often observe a grayish tinge of the mucous surface, 
which is due to the crowding of these cellular elements underneath and in 
the mucous membrane, for these newly -formed cells can be traced into the 
submucous connective tissue. Even where the inflammation remains 
catarrhal, as it does over certain areas in all cases of diphtheria, this infil- 
tration of the mucous and submucous tissues with cells is common. 

No certain and invariable chemical or microscopical difference has yet 
been established between the pseudo-membrane of croup as described in 
the appropriate chapter and that of diphtheria. The difference universally 
recognized is this, that while the croupous membrane in all situations lies 
upon the mucous membrane, and does not penetrate it, that of diphtheria, 
in the localities where it most commonly forms, namely upon the buccal, 
faucial, and laryngeal surfaces, penetrates and becomes blended with the 
mucous membrane, so that it cannot be detached by force without the risk 
of injuring this membrane, and lacerating its vessels ; moreover, by its 
presence in the mucous layer, it is apt to obstruct circulation in it and 
cause ulceration, even in the submucous tissue. 

During the height of the inflammation, it is astonishing often to see 
with what rapidity the pseudo-membrane returns, when removed by force. 
A few hours suffice to restore it as firm and extensive as before the inter- 
ference. In favorable cases this adventitious layer is detached in a few 
days, and is either expectorated or swallowed with the ingesta. Its sepa- 
ration is promoted by the secretions underneath, especially by pus, which 
is formed in abundance between it and the surface on which, and in which 
it lies. In most cases it does not separate in mass, but disappears, by pro- 
gressive liquefaction, a little less remaining at each visit till all is detached. 

Such are the appearances, character, and history of the pseudo-membrane 
in this malady. Although its common seat is upon the fauces, and in mild 
cases it occurs only upon the fauces, nevertheless all the mucous surfaces 
are liable to be attacked by the inflammation, in consequence of infection 
of the blood, and therefore in severe cases, and even in cases of moderate 
severity, we often find the product elsewhere, as well as upon the fauces, 
and in localities where from its mechanical effect it greatly increases the 
danger and even compromises life. The mucous membrane of the nostrils, 
mouth, larynx, trachea, oesophagus, stomach, intestines, conjunctiva, vagi- 
na, and even the delicate lining of the middle ear, are at times the seat of 
diphtheritic inflammation, with the characteristic product. If the exuda- 
tion occur in the larynx, or air-passages below the larynx, we have diph- 
theritic croup, more dangerous even than true croup ; if upon a surface 
concerned in the digestive process, this function is more or less interfered 
with. In a case which occurred in the Nursery and Child's Hospital of 
New York, the surface of the stomach was almost completely lined with 
the diphtheritic formation, so that the function of this organ was ap- 
16 



242 DIPHTHERIA. 

parently nearly or quite abolished. The occurrence of the pseudo-mem- 
brane in the nares is common, and is attended by the discharge of thin 
mucus and pus, but though inconvenient to the patient, its mechanical 
effect is not dangerous, except in the nursing infant, in whom it interferes, 
more or less, with lactation. The thin irritating discharge produces exco- 
riation around the nostrils, and upon the upper lip. I have met only one 
case of diphtheritic inflammation of the intestines, in which the diagnosis 
was certain. A physician, in whose family severe diphtheria had just 
occurred, took what was believed to be typhoid fever. After a long sick- 
ness he expelled, per rectum, about one foot of diphtheritic pseudo-mem- 
brane in a cylindrical form, evidently produced upon the intestinal walls. 
In the subsequent months the patient suffered - from constipation, and 
severe abdominal pains, apparently due to contraction in the healing of a 
large diphtheritic intestinal ulcer. Death finally occurred from this state 
of the intestines. The occurrence of the diphtheritic pellicle upon the 
vulva and vaginal walls is occasionally observed, as in one of the cases 
related above. Its occurrence upon the uterine surface is very rare, ex- 
cept in the parturient woman, in whom it is said to occur by preference 
upon that part from which the placenta has been detached. I have met 
only one case of uterine diphtheritic inflammation, the disease having been 
contracted during or immediately after parturition, and ending fatally with 
all the symptoms of acute metritis within the first week. 

In mild cases of diphtheria, in which the pseudo-membrane is small, 
and quite superficial, penetrating but little the mucous membrane, in which 
it is imbedded, there is little danger of septic poisoning. But in grave 
cases, in which the diphtheritic pellicle is extensive, and deeply imbedded, 
so that the lymphatic and blood vessels are in immediate relation with its 
under surface, the conditions in which septicaemia occurs are present, as 
scon as decomposition begins. Therefore septicaemia is properly regarded 
as a not infrequent and dangerous accident in severe diphtheria, but it is 
obviously very difficult to distinguish septic from diphtheritic blood pois- 
oning, from the symptoms. Septicaemia is most apt to occur in those 
cases in which the pseudo-membrane has become dark gray, and friable, 
from decomposition, producing an ichorous discharge and offensive breath, 
and in cases in which blood escapes from the capillaries underneath. 

Absorption of the poisonous substance produces inflammation of the 
lymphatic vessels, along which it passes, and of the lymphatic glands, 
which these vessels enter. The adenitis also gives rise to inflammation of 
the periglandular connective tissue, so that the neck is thickened, hard, 
and tender. If we examine a gland which is swollen and inflamed by the 
toxic absorption, we will find that its bloodvessels are congested, and its 
cells have undergone hyperplasia. The periglandular connective tissue is 
©edematous, and sometimes infiltrated with lymphoid cell-nuclei and pus- 
corpuscles. Capillary hemorrhages are also common in the connective 



ANATOMICAL CHARACTERS. 243 

tissue, and micrococci are found in the lymphatic vessels, lymphatic glands, 
and in the connective tissue. 

Bronchitis also occurs in certain cases. It is usually simple or catarrhal, 
but in some patients it is pseudo-membranous in some of the tubes, espe- 
cially in the larger, or in those which are located in the posterior part of 
the chest, while in the other tubes it is catarrhal. 

If death occur from obstruction in the air-passages, the lungs will be 
found much reduced in size, the anterior superior portions being pale from 
lack of blood, and perhaps emphysematous, while the posterior and in- 
ferior portions have a dark-red color, many of the lobules being collapsed, 
and others not only collapsed, but in the commencement of catarrhal 
pneumonia. This difference in the state of different parts of the lungs, in 
those who have died of suffocation in consequence of the presence of the 
false membrane in the air-passages, receives partial explanation from the 
seat of the exudation in the bronchial tubes, for in those who perish from 
this cause the exudation is found chiefly in such tubes as pass to the pos- 
terior and inferior parts of the organ, while such as pass to the superior 
and anterior lobules remain free from it. In some instances, in parts of 
the lungs fibrin can be traced along the minute bronchial tubes into the 
alveoli, where it forms a network containing in its interstices pus, and 
sometimes blood-corpuscles, and more or fewer micrococci. Pneumonia 
is also a common complication sometimes resulting from downward ex- 
tension of the bronchitis, but in other instances occurring independently. 

The muscular fibres of the heart in diphtheria, as in all acute infectious 
diseases, are liable to granulo-fatty degeneration, so that they become 
softer, have a color which French writers liken to that of new leather or 
coffee and milk. This degeneration has been observed only in a certain 
proportion of the more malignant cases, and is far from being uniform. 
Any portion of the heart may undergo this change. It may occur in the 
columnar earner, or in the walls of the organ. White fibrinous clots 
are sometimes observed in the cavities of the heart after death from 
diphtheria, and it is the accepted belief, in consequence of the symptoms 
and mode of death, that in a certain proportion of such cases the clots 
are ante-mortem, having formed some hours before the agony. It is well 
known that similar clots, thought to be ante-mortem, are not infrequent 
in fatal scarlet fever. 

The blood in cases of a severe type is usually darker than in health, and 
the clots soft. After death from diphtheritic laryngitis, it is also dark 
from excess of carbonic acid in it. The chemical changes which the blood 
undergoes in diphtheria are little known. MM. Andral and Gavarret 
found a notable diminution of fibrin in grave infectious diseases, as typhoid 
fever, puerperal fever, etc., and it is not improbable that the same is true 
of diphtheritic blood, although the exudation of fibrin is so abundant. 
Mr. Bouchet and others have found a notable excess of the white corpus- 



244 DIPHTHERIA. 

cles in the blood in a considerable proportion of diphtheritic patients, so 
that, instead of three or four in the field of the microscope, as many as 
sixty have been counted. M. Sanne writes of diphtheria : " It is neces- 
sary to recognize in the dark-brown blood an abnormal accumulation of 
the debris of the red corpuscles, debris of little abundance in the normal 
state, augmented considerably under the noxious influence of the diphthe- 
ritic poison, which has rapidly produced destruction of a great number of 
globules" (Traite de la Diphtherie, page 107, Paris, 1877). Small extra- 
vasations of blood in various organs are among the most constant lesions. 
They have been most frequently observed in the brain and its meninges, 
the lungs, spleen, and kidneys. In one of the cases which I examined 
after death in the N. Y. Infant Asylum, as I have stated above, the extra- 
vasations in and under the gastric mucous membrane produced a mot- 
tling as great as that of the skin in measles. 

No notable changes have thus far been observed in the nervous centres, 
with the exception of the apoplectic foci, and softening of adjacent brain 
substance, and the congestion present when death has resulted from diph- 
theritic croup. But certain degenerative changes have been observed in 
peripheral nerves, as well as in the muscles in parts affected with diphthe- 
ritic paralysis. Thus, in nerves from a paralyzed palate, certain nerve 
tubes have been observed nearly or quite destitute of medullary matter, 
though this is not common, but many tubes are found to contain fatty 
granules, the result of retrogressive metamorphosis (MM. Charcot and 
Vulpian). 

The liver does not appear to be seriously engaged or its function com- 
promised. In most acute infectious diseases which are fatal in consequence 
of blood poisoning, the spleen is apt to become softened and somewhat en- 
larged, but this does not always occur in diphtheria. It will be recollected 
from the cases related above that the spleen may not be perceptibly enlarged 
or softened. 

The kidneys of all the internal organs are most frequently affected, as 
is shown by the common occurrence of albuminuria. Parenchymatous 
nephritis, with the characteristic hyperemia and swelling, is the usual 
form of kidney disease which complicates diphtheria. In the albuminous 
urine are found hyaline and granular casts. This inflammation may begin 
early in grave cases, even as soon as the first or second day, but its com- 
mencement is ordinarily not till towards the close of the first week or in 
the second. It occurs in the majority of those severe cases which prove 
fatal from blood poisoning. Interstitial nephritis also occurs in certain 
cases, as in one of those related above, giving rise to an increase in the 
connective tissue. 

Symptoms In general, in the commencement of an epidemic, diph- 
theria is more severe and fatal than when the epidemic influence is abat- 
ing. The prominent symptoms, such as arrest the attention of the friends, 



SYMPTOMS. 245 

are often disproportionate to the gravity of the attack. Striking cases 
illustrative of this have occurred in my practice, the friends not supposing 
that there was any serious ailment, and not seeking medical advice till the 
fatal termination had nearly arrived. The initial symptoms are sometimes 
mild, such as chilliness or rigors, often slight, and succeeded by moderate 
febrile reaction, languor, and perhaps more or less headache, pain in the 
limbs or back, and impaired appetite. Still the patient may continue to 
walk about as if affected with slight and temporary ailment. Such cases in 
New York city frequently attend the schools, and do immense harm in pro- 
pagating the disease. The symptoms in these mild cases are often like those 
from a cold, for which light attacks of diphtheria are apt to be mistaken 
by the friends. With some, in mild as well as severe diphtheria, one of 
the first symptoms is slight tenderness or a sensation of fulness in the 
fauces. A distinguished clergyman of the Pacific coast, who fell a victim 
to this disease, dreamed, a few nights before he complained of illness, that 
his throat was cut. Doubtless the diphtheritic inflammation had already 
commenced, so that what seemed a foreAvarning had a natural explanation. 
So insidious was the commencement in this case that the disease had ad- 
vanced beyond all hope of relief when medical advice was first sought. 
But in most cases, other than those of a very mild type, the commence- 
ment is more severe, being attended by a temperature of 102° or 103°, or 
even 104°, with corresponding heat of surface, thirst, languor, loss or 
impairment of appetite, tenderness of throat, etc. Delirium as well as 
eclampsia may occur, but both are rare. The febrile reaction ordinarily 
abates considerably by the close of the second or on the third day, as I 
have noticed in many observations. 

The symptoms of invasion have less prognostic value in diphtheria than 
in most other infectious maladies. We meet cases with a severe besrin- 
ning, attended by delirium, which terminate in apparently complete 
restoration to health in less than a week, the presence of the characteristic 
pellicle upon the fauces and the occurrence of diphtheria in other members 
of the family rendering the diagnosis certain. On the other hand, a mild 
commencement sometimes ushers in a fatal form of the disease. This is 
notably true of those cases in which laryngitis supervenes, as it not infre- 
quently does in cases which begin very mildly. 

The fever which ushers in diphtheria abates, as stated above, after the 
second or third day, and subsequently, in grave as well as in benign cases, 
there may be but little or even no elevation of temperature. The diphthe- 
ritic poison does not therefore, like that of scarlet fever, exhibit any 
marked tendency to increase the animal heat. Even in profound and 
fatal blood poisoning in this disease, the thermometer shows the normal, or 
scarcely more than normal, temperature, so that the inexperienced practi- 
tioner is apt to be deceived in his prognosis. On the other hand, a con- 



246 DIPHTHERIA. 

tinued elevation of temperature with only moderate angina should lead the 
physician to examine for some complication, perhaps a nephritis. 

The tongue is usually moist, and slightly furred. The patient often 
vomits in the commencement, and, if this ceases or is seldom repeated, it is 
not a grave sign ; but vomiting occurring often, so that the food is rejected, 
and due often no doubt to uraemia, is not infrequent in severe cases. The 
appetite varies. Repugnance to food characterizes many of the gravest 
cases, and, if the child is compelled to take it, it is often rejected by 
vomiting. There are no notable symptoms referable to the state of the 
intestines. The stools usually appear normal, except as they are changed 
by medicines. 

The respiratory apparatus is not involved in the benign cases in which 
only the fauces are inflamed. But next to the fauces and posterior buccal 
surface, the Schneiderian membrane is most frequently involved of all the 
surfaces, and when the nares are inflamed, and are covered to a greater or 
less extent by the pseudo-membrane, there is more or less discharge, which 
may excoriate the upper lip, and cause incrustation around the entrance of 
the nostrils. This often renders respiration through the nostrils difficult. 
In cases having this severity there is usually at the same time considerable 
faucial swelling, so as to cause guttural respiration, which is most marked 
in sleep. But the most important symptoms pertaining to the respiratory 
apparatus, occur when the inflammation attacks the laryngeal surface, or 
this surface and those contiguous to and below it in the respiratory tract. 
Diphtheritic croup may be primary or secondary. In New York the 
secondary form most frequently occurs as a complication of measles, and 
as the rubeolar inflammation extends not only over the larynx and trachea, 
but bronchial tubes, the diphtheritic pseudo-membrane is apt to extend 
further downward than when the inflammation is primary. 

Diphtheritic croup often occurs at the commencement of diphtheria, so 
as to be and continue to be the predominant inflammation, but in other 
cases it supervenes after diphtheria has continued a few days. There are 
many mild cases, which give no anxiety as long as the inflammation re- 
mains faucial, but in which the whole aspect is within a day changed by 
the occurrence of croup, and the condition becomes one of imminent 
danger. Usually when diphtheritic croup occurs, there is a simultaneous 
if not pre-existing exudation upon the fauces. Occasionally in undoubted 
diphtheria the diphtheritic pellicle forms only upon the surface of the air- 
passages below the epiglottis, while the fauces present merely an inflamma- 
tory reddening, and the surface of the nares is either free from disease or 
only reddened. Thus, in January, 1875, I attended a child, aged two 
years and ten months, who died from a gradually increasing dyspnoea after 
a sickness of four days, having during his sickness moderate swelling of 
the tonsils, and general redness of the faucial surface, but without mem- 
branous exudation upon it. The symptoms and history of the case were 



SYMPTOMS. 247 

precisely those of true croup, but the diphtheritic nature of the malady- 
was clearly shown by the occurrence very soon after the death of the pa- 
tient of diphtheritic pharyngitis, with the characteristic exudation upon 
the fauces, of the two young women who nursed him. 

In New York, as will be seen by the table below, the predominant in- 
flammation in about one-fourth of the cases of diphtheria is the laryngitis. 

In addition to the accelerated pulse during the febrile stage and the slow 
and compressible pulse during the stage of profound blood poisoning, the 
chief symptoms, pertaining to the circulatory system, relate to the state 
of the heart, and the altered state of the blood which gives rise to hem- 
orrhages. The ante-mortem heart-clots, the weakened action of the heart 
from degenerated muscular fibres, the hemorrhages from the altered state 
of the blood, indicate a very dangerous condition of the circulatory appa- 
ratus. 

Very little attention had been bestowed upon the state of the kidneys, 
and the character of the urine in diphtheria, till Mr. Wade, of Birming- 
ham, discovered albuminuria, since which many observations in different 
epidemics, and localities, have established the fact that albuminuria occurs 
in a majority of cases of a severe type, and in many cases of diphtheritic 
laryngitis in which the type is not severe. Two conditions of the kidneys 
give rise to albuminous urine, namely, nephritis, which is the most com- 
mon, and venous congestion, which occurs in cases of embarrassed circula- 
tion, as in certain cases of diphtheritic laryngitis, and in obstruction from 
heart clots. The latter is comparatively infrequent. 

During the latter part of 1875, and in 1876, prior to August 1, I en- 
deavored to obtain and examine the urine in every case of idiopathic 
diphtheria, having a clear diagnosis, which came under my notice, both 
in family practice and in the institutions with which I have an official con- 
nection. Ordinarily, during the first week of a case, I found that the 
urine deposited urates on cooling, and that the nitric acid test showed a 
large relative quantity of urea, but I suspect that this was due to a some- 
what diminished quantity of urine. But the occurrence of albumen was 
of chief interest, and the results of the examinations as regards the presence 
or absence of this, are recorded in the accompanying table. In most of 
the cases the urine was examined several times in the course of the dis- 
ease, and, if albumen were present, a microscopic examination was also 
made. In nearly all the specimens which contained albumen — all but 
three or four — casts, usually granular, but now and then hyaline, and 
sometimes both kinds in the same specimens, were observed. In those 
cases of albuminuria which recovered, there were comparatively few 
casts, or none. If the albumen were abundant, and casts plentiful, the 
case was usually fatal, though not perhaps till after the lapse of three or 
four weeks, when death occurred with symptoms of exhaustion, paralysis, 
or feeble heart-action, sometimes with oadema of lungs supervening sud- 



248 DIPHTHERIA. 

denly, and, probably, formation of heart clots. The albuminuria, unlike 
that of scarlet fever, seldom occurred except in the grave cases ; and in 
the majority of instances it did not appear till near the close of the first 
week, or in the second, and, in a few instances, not till a later period. 
Although the albuminuria of diphtheria is much more grave than that of 
scarlet fever, it has in my practice been attended by much less serous 
effusion or dropsy, often by none which was appreciable. The urine, 
although containing a large quantity of albumen, ordinarily had nearly the 
normal appearance, instead of the smoky or hazy color so common in 
the albuminous urine of scarlet fever. 

I. Cases attended with the usual membranous exudation upon the fauces, 
with or without coryza, and without laryngitis or with only catarrhal 
laryngitis ; Jifty-eight cases. 



Died. 


Recovered. 


Result not 
stated. 


Total. 


With albuminuria . .13 


5 


1 


19 


Without albuminuria . 4 


27 


1 


32 


State of urine not recorded 3 


4 


. . 


7 



II. Gases attended with membranous laryngitis as the predominant in- 
flammation ; nineteen cases. 



Died. 


Recovered. 


Total. 


With albuminuria . . 4 


1 


5 


Without albuminuria . 2 


4 


6 


State of urine not recorded 7 


1 


8 



The mortality of the cases embraced in the above table was probably 
larger than the average in New York practice, for several of them were 
seen, in consultation, and their type was severe. Those in which the 
state of the urine could not be ascertained, were usually in children so 
young or so near death that it was impossible to obtain sufficient urine 
for examination. 

It is seen that in New York, where diphtheria is endemic, of 62 cases 
occurring in the course of about ten months, 24 were attended by albumi- 
nuria, and 38 were exempt. In a larger number of cases, of which I 
have preserved the records since 1876, I think that the proportion of al- 
buminous cases has been about the same, but obviously -during epidemics 
of a severe type, the proportion is larger than when the type is mild. 

An efflorescence is sometimes observed upon the skin during the time 
in which the temperature is exalted. It is the erythema fugax of derma- 
tologists, suddenly appearing and disappearing. This eruption, which is 
so common in the febrile and inflammatory affections of childhood, does 
not seem to present any peculiar characters in children. But there is 
another eruption, which I have several times observed, and of which I 
have preserved a drawing as it appeared in one case, which I have no 



.YMPTOMS. 249 

doubt is clue to diphtheritic toxaemia, or to septicaemia occurring in diph- 
theria. It appears after the sixth or seventh day, in the form of red 
points or spots, not more than a line in diameter, and interspersed with 
patches of larger size, and irregular margins, one to two inches in diame- 
ter. This roseolar eruption is slightly raised, like that of measles ; it dis- 
appears on pressure, and so far as I recollect it has, in my practice, ap- 
peared only in fatal cases. Occasionally extravasations of blood occur in 
and under the skin, like those occurring in the internal organs. The 
pallor of the skin, which diphtheritic toxaemia produces in the second and 
third weeks, is known to all who have had experience with this disease. 

Diphtheritic paralysis is described by some writers as a symptom and by 
others as a sequel. It usually begins during convalescence in the second 
or third week after the abatement of the inflammatory symptoms, but 
sometimes not till considerably later. It may on the other hand appear 
considerably earlier, during the stage of the development of the inflamma- 
tions, as early as the fifth or sixth day, or even as the second or third day 
from the beginning of the diphtheria (Sanne). When the paralysis begins 
at an early period it may cease, and reappear later, and in other parts. Its 
commencement may not be announced by any symptoms apart from the 
loss of muscular power, but in other cases there is febrile movement with 
albuminuria. The muscles most frequently affected are those of the phar- 
ynx, and upper part of the larynx. The muscles of deglutition are some- 
times so involved, that the food and drinks are not swallowed till after 
several successive efforts, and a part may be returned through the nostrils. 
A portion of the food sometimes enters the larynx, so as to produce vio- 
lent coughing. As we observe the dysphagia, it seems as if there must 
be pharyngitis, which renders deglutition difficult, but on inspecting the 
fauces we find no evidence of inflammation. The mucous membrane has 
recovered its normal appearance, and the nerves only are affected. The 
velum palati hangs flaccid and motionless like a curtain ; and the relaxed 
state of the muscles at the entrance of the larynx causes guttural respira- 
tion, or snoring in certain cases, which is especially marked during sleep. 
In severe cases the difficulty of swallowing may endanger suffocation from 
the lodgment of food in the larynx, and inspire dread of taking food on the 
part of the child. Tickling, and even pricking the velum fails to induce 
motion. In some there is only faucial paralysis, but in many the loss of 
muscular power occurs in other parts also. Whenever it occurs elsewhere, 
the pharyngeal muscles are nearly always involved at the same time. 
Diphtheritic paralysis may affect the motor muscles of the eye, causing 
strabismus ; the muscles of one side, causing hemiplegia ; of the legs, 
causing paraplegia ; or of an arm on one side and leg on the opposite. It 
does not commence simultaneously in the various muscles which are 
affected, but in succession, those first affected being for the most part 
the muscles of the pharynx. In some patients the muscles of the bladder 



250 DIPHTHERIA. 

are paralyzed, leading to retention of urine or difficulty in passing it. 
Paralysis in the limbs is frequently preceded by tingling or a sensation of 
formication. There is often not a total loss of sensation or of motion in 
the paralyzed part, but more or less numbness with difficulty rather than 
impossibility of motion. A few cases have been reported in which the 
paralysis was almost general, and some believe that they have met cases 
in which the heart was paralyzed, death occurring suddenly and unex- 
pectedly. Dr. J. B. Reynolds relates a case in the New York Journal of 
Medicine, May, 1860, in which there were not only strabismus, partial 
paralysis of the limbs, and paralysis of the muscles of the pharynx, so that 
food was regurgitated, but the head dropped forward so that the chin 
rested on the sternum. 

A majority of those affected with paralysis recover, although few regain 
the complete use of their muscles in less than one month, and many do not 
till between two and four months. 

Defect of vision is an occasional result of diphtheria ; some have pres- 
byopia ; others myopia ; some see double ; some are amaurotic ; while in 
others one pupil is more dilated than the other, or both pupils are dilated, 
and feebly sensitive to light. This impairment or perversion of vision 
gradually disappears as the vigor of system returns. 

Various theories have been advanced in explanation of the occurrence 
of the paralysis, as that of reflex irritation advocated by Brown -Sequard, 
that of anaemia, etc. A careful examination of the nervous centres, 
made in certain fatal cases, has revealed nothing which throws light on 
its etiology. That the diphtheritic virus causes paralysis by some special 
action is evident, for there is no other infectious disease which is attended 
and followed by paralysis so often as diphtheria. The most plausible 
theory is that recently brought to light by histological examinations, which 
have shown that the peripheral nerves in paralyzed parts have undergone 
degenerative changes, as mentioned above, so that under the neurilemma, 
we observe more or less granular matter, in place of the normal nerve 
tissue, or lying in this tissue. Among the many anatomical changes 
which the specific principle produces, those in the peripheral nerves must 
therefore be regarded as important, since pathological changes in the nerves 
which supply paralyzed muscles sanction the belief that they sustain a 
causative/relation to the paralysis. 

Diagnosis. — In most instances the diagnosis of diphtheria is readily 
made when the case has continued a few hours, for the characteristic false 
membrane is observed on inspection of the fauces. I have usually at my 
first visit been able to state the nature of the pharyngitis from its appear- 
ance. But there are cases which vary from the typical form in which the 
diagnosis is more or less difficult. The confervoid growth of sprue, when 
occurring upon the fauces, is sometimes mistaken for the false membrane 
of diphtheria, but the error of mistaking one for the other in cases which 



DIAGNOSIS — PROGNOSIS. 251 

I have met, has been due to hasty and careless examination rather than 
to any real difficulty in the discrimination. The peculiar product of sprue 
has but little depth and coherence, and is readily detached without injury 
to the mucous membrane or its vessels. If there is any doubt, the differ- 
ential diagnosis can be readily made by the microscope. 

Follicular pharyngitis, like diphtheria, commences with sharp fever, 
which, however, is ephemeral, and is attended with the formation of round 
white masses in the site of the follicles, usually over the tonsils only. 
These masses do not occur in patches, like those of diphtheria, except 
when two or three are in close proximity and unite, but at the same time 
a sufficient number are discrete to establish the diagnosis. Follicular pha- 
ryngitis often occurs in several members of a family at the same time, in- 
volves no danger, and is quickly cured. 

The diagnosis of diphtheritic from membranous laryngitis is often diffi- 
cult. Diphtheritic laryngitis is usually accompanied by more tumefaction 
of the lymphatic glands of the neck, and more discharge from the nostrils. 
Moreover the laryngitis is often secondary in point of time to the pharyn- 
gitis, so that in the first day of the former we observe so much faucial 
inflammation, that it is evident that the latter predominates ; whereas in 
true croup the laryngitis precedes and predominates. 

Often the diagnosis is made clear by the history. Thus a boy, aged 
two years and ten months, died of acute laryngo-tracheitis, lasting 
about four days. He lived in the suburbs of the city, where the houses 
were scattered, and where there had been no recent diphtheria. The 
case commenced with hoarseness, which gradually increased to a fatal 
obstruction in the air-passages, without any pseudo-membrane upon the 
fauces or upon any other visible part. This case seemed to be identical 
with the true croup with which we were familiar before the occurrence of 
diphtheria in New York ; and yet it was diphtheritic, for two or three 
days after the death of the child, the two young women who nursed him 
were affected with severe diphtheritic pharyngitis with the characteristic 
pseudo-membrane. 

Sometimes the occurrence of albumen in the urine, with or without 
fibrinous casts, aids in establishing the diagnosis, for it is more common 
in diphtheria than in croup. It is evident, from the above facts, that the 
diagnosis of diphtheritic from membranous croup, though easy in typical 
cases, is difficult if not impossible at the bedside in certain cases, especially 
when there is little or no exudation upon the fauces. 

Prognosis — No infectious disease presents greater differences in type 
or severity. In mild epidemics, with moderate fever, slight faucial swell- 
ing, and little extent of the pseudo-membrane, a large majority recover, 
and would recover even without treatment. Uncertainty of prognosis, of 
which even physicians of ample experience complain, is largely due to 
the fact that diphtheria terminates fatally in several distinct ways. Hence, 



252 DIPHTHERIA. 

while the patient may be secure as regards the more manifest and common 
conditions of danger, so as to justify a favorable prognosis in the opinion 
of the physician who attends him, the fatal result may suddenly occur 
from some unseen and unsuspected cause. 

Death in diphtheria may result from — 

1st. Diphtheritic blood-poisoning. 

2d. Probably, also, from septic blood-poisoning produced by absorption 
from the under surface of the decomposing pseudo-membrane. But it is 
difficult to distinguish the constitutional effects of sepsis from those pro- 
duced by the diphtheritic poison. Septic poisoning is obviously most 
apt to occur in those cases in which the pseudo-membrane is extensive, 
and deeply imbedded, and its decomposition attended by an offensive 
effluvium. Cervical cellulitis, and adenitis, which, when severe, cause very 
considerable swelling of the neck, appear to be often, if not usually, due to 
septic absorption from the faucial surface, the inflammation extending 
from the absorbents to the glands and connective tissue. Considerable 
tumefaction of the neck, therefore, seldom occurs in diphtheria or scarlet 
fever, without manifest symptoms of toxaemia, and is to be regarded as a 
sign of its presence. 

3d. Obstructive laryngitis. 

4th. Uraemia. 

5th. Sudden failure of the heart's action, either from the anaemia, and 
general feebleness, from granulo-fatty degeneration of the muscular fibres 
of the heart, which is liable to occur in all infectious diseases of a malig- 
nant type, or from ante-mortem heart clots. 

6th. Suddenly developed passive congestion and oedema of the lungs, 
probably due to feebleness of the heart's action, or to paralysis of the res- 
piratory muscles. I have known death to occur apparently from this cause 
during the period of supposed convalescence, and when the visits of the 
physician had been discontinued. Thus in a case in my practice, symp- 
toms of cedema pulmonum (moist rales in both sides of the chest, and em- 
barrassed breathing) suddenly occurred nearly one month after the disap- 
pearance of the faucial pseudo-membrane and inflammation. The urine, 
which had contained considerable albumen during the active period of the 
malady, had for some time shown no trace, or but slight trace of this prin- 
ciple by the proper tests. By active stimulation these symptoms entirely 
disappeared in a few hours, and the heart's action seemed normal, unless 
a little weakened. On the following day the same symptoms reappeared, 
and death occurred before I was able to reach the house. 

That physician obviously is least apt to err in prognosis, who recognizes 
the fact that patients are liable to perish in any of these different ways, 
and carefully examines in reference to all the conditions which involve 
danger. Many physicians, as I have had the opportunity to observe, are 
remiss in not examining more frequently the urine of diphtheritic patients, 



TREATMENT. 253 

for there is often a large amount of albumen in the urine in diphtheria, 
indicating a poisonous quantity of urea in the blood, and vet the appear- 
ance of the urine to the naked eye is probably normal. 

Among the symptoms which render the prognosis unfavorable are, 
repugnance to food, vomiting, pallor of countenance, with progressive 
weakness and emaciation from the blood-poisoning ; a large amount of 
albumen with casts in the urine, showing urremia, to which the vomiting 
is sometimes, but not always, attributable ; a free discharge from the nos- 
trils, or occlusion of them by inflammatory thickening, and exudation, 
showing that a considerable portion of the Scheiderian membrane is in- 
volved, hemorrhage from the nostrils or fauces, and obstructed respiration. 
In diphtheritic laryngitis, attended by obstructed respiration, a large ma- 
jority have thus far died, whether treated by the most approved inhala- 
tions or by tracheotomy. One, at least, of the above symptoms has been' 
present in most of the fatal cases which I have observed. 

Treatment It is remarkable that there is so little agreement in the 

profession in regard to the medicinal treatment of diphtheria, since this 
disease has now been under almost constant observation during the last 
twenty years in the principal cities of this country, and many epidemics 
have been closely observed and reported by intelligent physicians in the 
rural districts. The wide discrepancy, which exists in reference to the 
proper therapeutic measures, receives partial explanation from the fact of 
a wide difference of opinion as to the nature of diphtheria and its mode of 
commencement, but is more due to the fact that statistics of its treatment 
afford very unreliable, and often conflicting data by which to determine 
the proper medicinal agents. For scarcely any other disease presents 
such a diversity in type as diphtheria, from cases so mild, that nearly all 
recover, whatever the measures employed, to those so severe, that a large 
proportion die under the best possible treatment. And this difference in 
type may be observed in cases occurring at the same time in a great city 
like New York, or even in the cases, which two physicians, practising 
near each other, may be called upon to treat. Hence, one physician re- 
commends with confidence a medicine or mode of treatment, as eminently 
successful in his hands, which another physician of equal experience speaks 
disparagingly of. The theory relating to diphtheria which, in my opinion, 
has of late years done the most harm, is that which attributes it to low 
vegetable organisms, visible under the microscope, which alight upon one 
of the exposed surfaces, usually the fauces, where they excite local inflam- 
matory action, and if not promptly destroyed, are apt to penetrate the 
tissues, enter the blood, and establish a constitutional disease. Acceptance 
of this theory evidently leads to the employment of parasiticide medicines, 
the so-called antiseptics, or anti-ferments, externally and internally, to 
arrest and destroy the vegetable growth, their local use sufficing, according 
to the theory, in the early stage, when these organisms have passed no 



254 DIPHTHERIA. 

further than the surface, but their internal use being required in addition, 
if the malady have continued longer, and the disease have become general. 
Hence, in proportion as this doctrine came in vogue, carbolic acid, chlorine 
preparations, bromine, the sulphites, phenic acid, and, as the best repre- 
sentative of this class of medicines, and most powerful antiseptic, salicylic 
acid, attained at once prominence as the agents which would be most 
likely to cure diphtheria, by*destroying the cause. A solution of bromine 
and bromide of potassium, having been used, with apparent good results, in 
the antiseptic surgery of the army during the late war, has obtained under 
the influence of this theory some reputation in New York as a remedy for 
diphtheria employed externally and internally, and without the aid of 
other therapeutic agents. A certain number of drops are administered 
internally every hour, or second hour, properly diluted, and the same 
medicine undiluted, or with less dilution, is applied to the fauces with a 
brush at regular intervals. 

But experience, if sufficiently extensive, is the safe guide in therapeu- 
tics, and, according to my observations, internal antiseptic measures have 
not seemed to exert any marked controlling effect on the course of diph- 
theria. 

Thus in Case IV. related above, a child of "four years took, almost from 
the beginning of the sickness, a mixture of potassa and iron on the first 
hour, two grains of quinine on the second hour, and three grains of sali- 
cylic acid on the third hour, and this treatment was continued night and 
day ; and yet this child, having from the first taken sixteen grains of qui- 
nine, twenty-four of salicylic acid, besides the potash and iron daily, died 
after eight days with profound blood poisoning, having had many extrava- 
sations of blood. 

This case, which presented the ordinary history of fatal diphtheria, did 
not seem to be materially modified by the internal antiseptic treatment. 
It would apparently have done as well without it. It is but one case, 
though an average example, and I have not observed any other in which 
the internal use of antiseptics seemed to produce a curative effect. My 
knowledge, however, of the bromine treatment is limited to the four chil- 
dren of one family, and to the effects of its use, which have been reported 
to me by others. 

The theory that micrococci, or vegetable monads, are the specific prin- 
ciple of diphtheria, which suggests and justifies the antiseptic treatment, 
was promulgated to the profession by those who had seen less of diph- 
theria than many others, but had zealously used the microscope. Their 
opinion, based on microscopic examinations and experiments, plausible, 
because having the appearance of scientific exactness, was widely received. 
And since, according to this theory, diphtheria is at first localized at the 
point upon the surface where the micrococci are received, this opinion, so 
far as it was accepted, evidently led to the early energetic treatment of 



TREATMENT. 255 

the local ailment, and indifference as regards constitutional measures. It 
is interesting to observe how the profession have been led by theories to 
regard the local treatment of diphtheria as of prime importance, especially 
during the first stage of the malady. Twenty to thirty years ago, when 
Trousseau was making his observations on diphtheria, and his views had 
great w T eight with the profession in both continents, it was believed that 
those blood diseases, which were communicated by inoculation, were at 
first local, even after the specific inflammation had appeared at the point 
of inoculation. Syphilis, for example, could be cured, it was thought, by 
proper applications to the specific eruption, if made within a certain number 
of days, and before the poison had entered the blood. In the same way it 
was believed that diphtheria is commonly received by inoculation, as it 
confessedly sometimes is, and could be cured by early applied local meas- 
ures. Hence Trousseau recommended to attack the pseudo-membrane, 
with what he designates " savage energy." After a time it began to be 
believed that the acute infectious diseases are already constitutional, al- 
though contracted by inoculation, when the specific eruption or lesion has 
appeared upon the surface, and that therefore no local treatment can pre- 
vent blood contamination, since it is already present. jNTow, when this 
opinion was received generally by the profession, and diphtheria began to 
be regarded as a constitutional malady, in its inception, as much as scarlet 
fever or measles, the promulgation of the bacterian theory exerted a retro- 
grade influence, so that it seemed for a time, as if the old mode of treat- 
ment of the age of Bretonneau, and Trousseau, would be restored. At 
this time there appeared in our language the exhaustive volumes of Ziems- 
sen's Encyclopedia, containing the cream of German medical literature, 
and as German physicists are most patient and exhaustive investigators, 
these volumes occupied the centres of our private libraries, and were pointed 
out as the means, which would be likely to elevate the profession of this 
country to a higher standard of medical knowledge. The treatise on diph- 
theria contained in this encyclopedia, the most minute of any on this subject 
in the English language, was eagerly sought for and read, and an immense 
amount of harm done. The writer of this treatise is fully committed to 
the bacterian theory, and the section relating to treatment begins thus : 
" In diphtheria we have to deal at first with an infection, which is local- 
ized, and afterwards with a general disease resulting from this, out of which 
may ultimately be developed still a later affection of various organs," and 
he discusses first the local treatment, as of paramount importance, and 
secondly, the general treatment. It was a great misfortune, that a treatise 
like that by Sanne had not appeared in place of the one published. But 
the mischief was done, the brush and inhalations were made the potent 
instrument of cure, and constitutional remedies held the second place, and 
were believed to be unnecessary, except when local treatment had failed 
to destrov the micrococci, and the second stage, or that of general infec- 



256 DIPHTHERIA. 

tion had arrived. For a time this theory has had its influence on prac- 
tice, but unpleasant experiences have taught, and are teaching physicians, 
that local measures, however early and perseveringly employed, do not 
protect the system from the diphtheritic poison, do not prevent the occur- 
rence of unmistakable symptoms of general infection in all cases of a grave 
type. Whatever the theory, experience gradually establishes the fact, in 
the minds of all observing physicians, that constitutional treatment is of 
paramount importance in diphtheria, as it is in that other malady, which, 
in my opinion, is most nearly akin to it, namely, scarlet fever, except 
when the danger is located in the larynx. 

Since December, 1875, I have examined minutely, and preserved 
records of, 104 cases of primary diphtheria, occurring either in my private 
practice, or seen by me in consultation, besides observing cases, and wit- 
nessing autopsies in the New York Foundling Asylum, where diphtheria 
was endemic nearly two years. From these observations, as well as from 
what I have been able to learn from other physicians, I am persuaded that, 
in order to secure the best treatment, constitutional and local, of diphtheria, 
it is necessary that the physician should accept the following proposi- 
tions : — 

1st. The specific principle of diphtheria, in all probability, enters the 
blood, in ordinary cases, through the lungs ; and after an incubative period, 
which varies from a few hours to seven or eight days, produces the symp- 
toms which characterize the disease. 

2d. Facts do not justify the belief that the system can be protected by 
antiseptic or preservative medicines administered internally. A quantity 
of this kind of medicine, introduced into the system, sufficient to preserve 
the blood and tissues from the action of the diphtheritic virus, would, 
there is every reason to think, be so large as to arrest molecular action, 
and therefore the functions of organs, and occasion death. 

3d. There is no known antidote for diphtheria, in the sense in which 
quinia is an antidote for malarial diseases, and no more probability that 
such an antidote will be discovered than for scarlet fever or typhoid fever. 

4th. Diphtheria, like erysipelas, has no fixed duration. It may cease 
in two or three days, or continue as many weeks ; but the specific poison 
acts with more intensity in the commencement than subsequently, and its 
energy gradually abates. Hence, diphtheritic inflammation, which arises 
in the beginning of diphtheria, as laryngitis, is more severe and dangerous 
than when the malady has continued a few days. 

5th. The indication of treatment is to sustain the patient by the most 
nutritious diet, by tonics, and stimulants ; and to employ other measures, 
general and local, as adjuvants, to meet special indications which may 
arise. The rules of treatment appropriate for scarlet fever, apply for the 
most part to diphtheria. Local treatment of the inflammations should be 
unirritating, and designed to prevent putrefactive changes, and septic 



STIMULANTS. 257 

poisoning. Irritating applications which produce pain lasting more than 
a few minutes, or which increase the area or degree of redness, are apt to 
do harm, and increase the extent and thickness of the pseudo-membrane. 

General Treatment. — This may be conveniently considered under the 
three heads, food, stimulants, and tonics. All physicians of experience 
recognize the importance of the use of the most nutritious and easily 
digested food, and the preservation of the appetite — for the safety of the 
patient requires that he should retain, as far as possible, his flesh and 
strength. The more nutritious and easily digested the food, given in suffi- 
cient quantity, with the appetite preserved, the less, obviously, the danger 
of the fatal prostration, which so frequently occurs suddenly and unexpect- 
edly in grave cases. Beef-tea, or the expressed juice of meat, milk with 
farinaceous food, etc., should be administered every two or three hours, or 
to the full extent, without overtaxing digestion. Failure of the appetite, 
and refusal to take food, are justly regarded as very unfavorable signs. 
One objection to the use of the brush, instead of spraying the fauces, with 
the atomizer, is that it is more apt to provoke vomiting, by which nutri- 
ment, that is so much required, is lost. In malignant cases of diphtheria, 
as in scarlet fever of a similar type, patients are sometimes allowed to 
slumber too long without nutriment. It is the slumber of toxaemia, and 
should be interrupted at stated times, in order to give the food. 

Stimulants — M. Sanne, in his elaborate treatise on diphtheria, says : 
" De tous les antiseptiques donnes a Pinterieur, l'alcool est de beaucoup le 
plus siir. Plus l'infection est prononce, plus il faut insister sur les com- 
poses alcooliques." He states that Bricheteau reports the history of a 
patient, who took daily, during the diphtheria, a bottle and a half of the 
wine of Bordeaux, without the least symptom of intoxication or headache. 
A somewhat similar case was reported to me, in which nearly a bottle of 
brandy was given in less than twenty-four hours, without any ill effect, 
and an apparent good result on the general course of the disease. The 
same rule holds true in diphtheria as in other acute infectious maladies, 
that while mild cases do well without alcoholic stimulants, they are re- 
quired in cases of a severe type, and should be administered in large and 
frequent doses, whenever pallor and loss of appetite, or of strength and 
flesh, indicate danger from the diphtheritic or septic infection. It matters 
little how the stimulant is administered, whether milk-punch or wine-whey, 
provided that the proper quantity is employed. 1 

1 Dr. E. N. Chapman, of Brooklyn, a physician of large experience, considers 
alcohol almost a specific for diphtheria. I believe, from my observations, that, if 
given early and frequently in grave cases, as, for example one teaspoonful every 
half hour of brandy or Bourbon whiskey, it does have a tendency to render the 
disease more tractable, and that it therefore affords important aid in saving the 
patient's life, and I am willing to allow that it is as nearly a specific as any other 
agent. Bnt to be instrumental in saving life in malignant cases, it must be given 
17 



258 DIPHTHERIA. 

Of the vegetable tonics, cinchona, or its important alkaloid principle, 
quinia, is more commonly employed than any other medicine, and there is 
probably none which answers the purpose better. The compound tincture 
of cinchona, and the fluid extract, have been used and recommended by 
physicians of experience ; but quinia is more conveniently employed, and 
is regarded by a large proportion of physicians as the most useful of all 
therapeutic agents in the treatment of this malady. But there is great 
difference of opinion in regard to the quantity which is required each day, 
and the size and frequency of the doses. It is sometimes administered in 
small doses, as one grain every three or four hours, for its supposed tonic 
effect ; and again in doses sufficiently large to produce an antipyretic effect, 
as from twenty to forty grains per day. It is prescibed by some physi- 
cians in two or three large doses per diem, as ten- or fifteen -grain, and 
by others in small and frequent doses. That quinia does not exert any 
special or peculiar action in diphtheria, and is beneficial in the same way, 
and no further than in other acute infectious diseases, is, I think, generally 
admitted by the profession ; for large doses do not exert that controlling 
effect, which we would expect from a specific, as is shown by cases like 
the following, which are not infrequent, during severe epidemics : — 

C, aged four years, male, was examined by me in consultation, on 
February 10th, 1876. I learned that he had apparently contracted diph- 
theria from the escape of sewer-gas through a defective trap in the little 
room where he slept, and that the disease began after midday on February 
6th, with fever. At 10 P.M. of the same day, when visited by the family 
physician, the temperature was 103°, and the fauces were red, but without 
any pseudo-membrane. Four grains of quinia were ordered to be given 
every two hours, and ten drops of the tincture of the chloride of iron, with 
two grains of the chlorate of potassa, to be give three times hourly. On 
the 7th the exudation covered both tonsils and the half arches ; tempera- 
ture 102^° ; evening, temperature 100° ; pulse 128. 8th. Is playful; pulse 
100 ; has slight swelling of the cervical glands ; evening, some extension 
upward of the pseudo-membrane ; has vomiting. 9th. Pulse 144; vomits 
often. 10th. At 3 P.M. began to grow worse ; pharynx and nostrils 
covered with the exudation. 



boldly from the start. If there is marked diphtheritic toxaemia, when its use is 
commenced it will not save life, but it may prolong it. Although an advocate of 
the liberal use of alcohol I cannot regard this agent as a specific. When I com- 
menced serving in the N. Y. Foundling Asylum in May, 1878, the quarantine wards 
contained four children, between the ages of three and five years, who had been 
sick a few days with severe diphtheria, and it was evident at a glance that they 
must soon perish with the ordinary mild sustaining treatment. Quinine, iron, the 
most nutritious food, and a moderate amount of alcoholic stimulants were being 
given, and we determined to increase the Bourbon whiskey to one teaspoonful 
every twenty to thirty minutes, day and night. Nevertheless, whatever the result 
might have been with the earlier commencement of this treatment, the blood poi- 
soning was now too profound, and one after the other died. 



LOCAL TREATMENT. 259 

It was impossible, at the time of my visit, to obtain any of the patient's 
urine for examination, and death occurred a few hours afterwards from the 
toxaemia. Forty-eight grains of quinia daily, administered from the first 
day, had no appreciable effect in staying the fatal progress of the malady, 
had no such effect as would be likely to follow, were its action specific or 
antidotal. But there are two advantages from the quinia treatment, which 
explain the confidence reposed in it by the profession : 1st. It has an anti- 
pyretic effect in doses of from three to five, or more, grains. 2d. In mode- 
rate doses it is one of the most reliable tonics. But high febrile movement, 
requiring an antipyretic, I have seldom observed in diphtheria, except in 
the first forty-eight hours ; and if, during this time, the febrile movement 
be such that an antipyretic is required, quinia in the larger doses is pre- 
ferable, in my opinion, to any other remedy. In its subsequent use, 
namely, as a tonic, two grains may be administered every two to four 
hours. Bat other bitter mixtures, which have been found to be the most 
useful tonics in general practice, perhaps would meet the indication nearly 
or quite as well. 

There is the same difference of opinion in regard to the use of iron, as 
to the use of quinia. Some prescribe the tincture of the chloride of iron, 
as the sole remedy in large and frequent doses, and others in smaller doses, 
as an adjuvant to the vegetable tonic. 

The internal treatment which I have found most satisfactory for a child 
of five years is the following : — 

fy. Quinise. sulpliat. ^ss ; 

Elix. adjuvantis (Caswell and Hazard's), 
Yel elix. tarax. conip., Jij. Misce. 
Give one teaspoonful every two to four hours ; and hourly, between, one tea- 
spoonful of the following : — 

R-. Tine, ferri chloridi, ^ij ; 
Potas. chlorat., ^ij ; 
Syr. simplie., §iv. Misce. 

The tonic effect of the iron is not impaired by the chlorate of potassa, 
the latter being added to the mixture, on account of its local action on 
the inflamed surface. 

The citrate of iron and ammonia alone, or in combination with carbon- 
ate of ammonia, may be given in two-grain doses, dissolved in simple 
syrup, in place of the above mixture, when the inflammation of the fauces 
has considerably abated or is moderate. If the patient improve, and the 
disease begins to decline, the intervals between the doses maybe lengthened, 
but the tonic should not be entirely discontinued, until the patient is far 
advanced in recovery, on account of the dangerous sequelae, which take 
their origin in an impoverished state of the blood. 

Local Treatment. — It is important to keep in mind the purpose for 
which local measures should be employed, as stated above. It is to reduce 



260 DIPHTHERIA. 

the inflammation of the mucous surfaces, and destroy the diphtheritic poi- 
son, and contagious properties in the pseudo-membrane, and to destroy the 
septic poison, and prevent its absorption, if any forms. Forcible removal 
of the pseudo-membrane, irritating applications, the use of a sponge or 
other rough instrument, for making the applications, should be avoided as 
likely to do harm. The applications should be made either with a large 
camel's-hair pencil, or, better for most of the mixtures employed, with the 
atomizer. The hand atomizer, like Richardson's hard rubber, which is of 
simple construction, while it carries a heavy spray from the curved tube, 
whicli is introduced over the tongue, is very useful, but the use of the 
steam atomizer is more convenient, and is preferable in severe cases. 
The following mixtures I am in the habit of using with the atomizer : — 

1. ]£. Acid, salicylic, £ss ; 

Glycerins, ^ij ; 

Aq. calcis, ^viij. Misce. 

2. $. Acid, carbolic, gtt. xxxij ; 

Glycerins, Jij ; 

Aq. calcis, £vj. Misce. 

3. ]£. Acid, carbolic, gtt. xxxij ; 

Potas. chlorat., £iij ; 
Glycerins, 3 iij ; 
Aquae, t |v. Misce. 

Half a dozen to a dozen compressions of the bulb of the hand atomizer 
cover the surface of the throat more effectually with the liquid than can 
be done by several applications of the brush, and it is usually not dreaded 
by the patient. Diminution of size of the pseudo-membrane under the 
use of the spray is a favorable sign, but if it do not diminish, its presence 
can do little harm, provided that it is properly disinfected. 

In most cases of diphtheritic inflammation of the fauces the spray suf- 
fices for local treatment, but the following mixture, applied by a large 
camel's-hair pencil, is also very effectual, immediately converting the 
pseudo-membrane into an inert mass, and putting a stop to all movements 
of the bacteria which swarm in it, as I have observed under the micro- 
scope : — 

$. Acid, carbolic, gtt. viij ; 

Liq. ferri subsulphat., sjij. — iij ; 
Glycerins, ^j. Misce. 

This may be used two or three times daily, between the spraying, or 
oftener without the spraying. It is not irritating (such an effect would 
condemn it), but it is dreaded by most children, on account, of the unplea- 
sant " puckering," which it produces. 

That form of diphtheritic inflammation which most imperatively re- 
quires local treatment, and in which local measures are of more importance 
than the constitutional, is obviously the laryngitis. Catarrhal laryngitis 
sometimes occurs in diphtheria, as I have occasionally observed in the 



DIPHTHERITIC CROUP. 261 

dead-house, without producing any marked symptoms, but the pseudo- 
membranous laryngitis of diphtheria is also common, and, as all know, 
is one of the most dangerous forms of disease. 

Diphtheritic Croup. 

Of the 104 cases of primary diphtheria, which I have alluded to above, 
as having been seen by me in family practice, since December 1, 1875, 
and notes of which I have preserved, in twenty-five the predominant 
inflammation was pseudo-membranous laryngitis. Cases in which there 
Avas some huskiness or hoarseness of voice, but no obstruction in the 
respiration, were not included in this number. Of these twenty-five 
cases, in which there seemed to be no reasonable doubt of the presence 
of a laryngeal pseudo-membrane, nine recovered, two by tracheotomy, 
and seven by the inhalation of the spray. Of the sixteen who died, 
upon two tracheotomy was performed, while the others were treated 
by the spray. It will be admitted, I think, that recovery of nine in 
twenty-five cases was an exceptionally good result, and was probably 
in part due to mildness in the type of diphtheria, during a portion of the 
time, in which these cases occurred, for if the type is severe the exudation 
is more abundant, and the exudative process continues longer. But those 
who observe carefully the effects of the spray (lime-water being used in 
the atomizer, as the most powerful solvent which can be safely employed), 
must admit that it is the most effectual agent at our command, for treat- 
ing this very fatal affection. The following cases may be cited as examples, 
showing what may be accomplished by the spray : — 

L., ret. 9 months, began to have croupy cough on February 16th, 1877, 
but it was slight at first, so as to attract little attention. Gradually this 
symptom became worse, and on the 19th I was asked to see her. At this 
time both inspiration and expiration were noisy, the cough frequent and 
croupy, the temperature 101°, and the fauces red, but without any pseudo- 
membrane upon them. In addition to the internal treatment, the above 
aSo. 2 mixture was ordered to be used every half hour to every hour. On 
the 2 2d small patches of pseudo-membrane were observed upon the fauces, 
the noisy respiration and croupy cough remained with little change, and 
the same treatment was continued. 

2-ith. Symptoms worse ; temperature 103° ; respiration still more em- 
barrassed, and the sternum is depressed in each respiration. Evening, 
temperature 101° ; respiration 40 ; pulse 136 ; urine scanty, none of which 
can be collected for examination. The steam atomizer is to-day substi- 
tuted for the hand atomizer, and its constant use directed. 

2oth. No lividity of fingers or lips, but very great dyspnoea ; struggles 
for breath at times, with a wild expression of the eyes ; respiration 40 ; 
pulse 164; temperature 103°. On the evening of this day, it did seem 
that the child would die before morning, and I greatly regretted that 
tracheotomy had not been performed, and would then have prepared for it, 
except for the opposition of the family. The Xo. 1 mixture was now 
substituted for tin; Xo. 2, and used without intermission. 



262 DIPHTHERIA. 

2Qth. Respiration 48, its character as before, but the mother states that 
the cough is somewhat looser; temperature 103|- . The membranous 
exudation has disappeared from the fauces. From this time there was 
gradual improvement, and in a few days the child was out of danger. 

In the same month in which the above case occurred, diphtheritic 
laryngitis appeared in two other families in my practice, and the following 
histories of them w 7 ill also show the probable good effects of the atomizer: — 

B., ret. 13 months, began to be croupy on February 14. On the 16th, 
when visited by me, there w 7 ere small isolated patches of pseudo-membrane 
upon the fauces, and the uvula was completely covered by this exudation. 
The cough w T as croupy, but the respiration was much easier than in the 
above case, and there was much less hoarseness of voice. The No. 2 
mixture was used every half hour with Delano's hand atomizer, and the 
symptoms, which never showed any immediate danger, gradually abated. 

B., a girl, ret. 4 years, living in the east side of the city, began to be 
hoarse on February 14, and on the loth the dyspnoea became so urgent, 
that the attending physician performed tracheotomy. A cast two inches 
in length, circular, and evidently extending nearly to the bifurcation, was 
expectorated from the opening, after which the respiration was easier. 
Her temperature was constantly under 100°. A few days after the ope- 
ration, symptoms of profound blood poisoning occurred. The urine was 
very albuminous, and it contained casts. The edges of the opening into 
the trachea became covered with the diphtheritic pellicle, and the charac- 
istic offensive odor was observed. Her death occurred on February 22. 

The second child, ret. 20 months, began to be hoarse on February 15, 
and was visited by myself with the attending physician on the 17th. Her 
temperature was 101° ; her fauces were red, but with only small patches 
of exudation, and her respiration was embarrassed and noisy, so as to be 
heard in the adjoining room. We prescribed, in addition to sustaining 
remedies, the constant use of the No. 1 mixture through the steam atomizer. 
Some of the time tw 7 o steam atomizers threw the spray upon the face of 
the child. It w T as obvious within a day or two, that the obstruction within 
the larynx had not increased, and with the constant use of the instruments 
night and day the inflammation gradually abated, and the life of the child 
w r as saved. 

These cases indicate, in my opinion, the proper course of treatment in 
diphtheritic laryngitis, but while we accord to local measures the first 
place in the role of therapeutic agents for this form of inflammation, in- 
ternal treatment should not, as a rule, be suspended. Even mild cases of 
diphtheritic laryngitis may end fatally by systemic infection after the ob- 
struction in the larynx is removed as in the above case, in which trache- 
otomy w 7 as performed, although the temperature during the period of the 
dyspnoea had been constantly under 100°. 

In diphtheritic croup the steam atomizer, which produces a constant 
application of the spray, should be used. If the inflammation do not be- 
gin to yield, and death seems imminent, tracheotomy should be considered. 
During an epidemic of severe type it will not, with an occasional excep- 
tion, save life, but when the type is mild a considerable proportion recover 
after the operation with judicious subsequent treatment. When the type 



PREVENTIVE MEASURES. 263 

was severe in New York, and blood poisoning a prominent feature, one 
of our surgeons operated about forty times with only two recoveries, and 
the experience of others was about the same, but during the last two years, 
with a milder type, the result has been much more favorable. Trache- 
otomy should therefore be performed as a last resort in certain cases. 

Unless in comparatively rare instances, there is only one other diphtheri- 
tic inflammation which requires special treatment, namely, that affecting 
the Schneiderian membrane. This membrane, in sensitiveness and liability 
to irritation, is intermediate between the conjunctiva and buccal or faucial 
membrane, and, therefore, when inflamed it requires milder applications 
than such as are appropriate for the fauces. Applications suitable for the 
fauces, would, if thrown into the nostrils, be too painful, and might in- 
crease the inflammation. I know no better treatment of the nostrils, than 
to inject with a small syringe one to two teaspoonfuls of the following 
mixture every third or fourth hour. It should be used at the temperature 
of the body, with the head thrown back and the eyes covered with a 
cloth. I have sometimes employed it with the atomizer: — 

I£. Acid, carbolic, gtt. xxiv ; 
Glycerinse, ^ij ; 

Aquae, Jvj. 

Diphtheritic paralysis requires the use of strychnine with tonics. I 
ordinarily employ the elix. phosphat. ferri, qui, et strychnine of the shops. 
Each drachm of this contains gr. fa of strychnia, and by dilution with 
water the proper dose can be administered to a child of any age. Thus, 
recently, a child aged six years, having paralysis of the muscles of the 
pharynx, recovered in about one week, by the use of one drachm of this 
medicine daily, given in four or five doses. I have not found it necessary, 
in any case which I have observed, to employ electricity, but it is no 
doubt useful in expediting recovery, especially if the paralysis is in the 
limbs. The anaemic state which succeeds diphtheria requires the use of 
iron for several weeks. 

Preventive Measures The occurrence of diphtheria in a family 

necessitates the prompt removal of other children of the family either out 
of the house or to a distant part of it, and the disinfection of the room, 
and the handkerchiefs, and other linen, and spittoons employed. The 
diphtheritic like the scarlatinous virus may remain for weeks or months in 
a locality or apartment. In East Fifty-fifth Street two families resided 
in a brown-stone house, the sanitary condition of which was apparently 
good. In December, 1874, diphtheria occurred in one of these families, 
who occupied the lower floor and the basement, causing the death of two 
of the children. The other family, in order to escape the danger, imme- 
diately removed to another part of the city, where they remained two 
months, returning home on March 6th. On March 14th and 15th, eight 
and nine days after the return, their two children, aged 2^ and 4^ years, 



264 PEKTUSSIS. 

who had been allowed free access to the room in which the fatal cases had 
occurred, also took severe diphtheria, one of them dying. 

In another family, living in the suburbs of New York, the mother con- 
tracted diphtheria from her brother's child, who died of the malady a few 
blocks distant. Returning home, she occupied a small room, remaining 
constantly in it, and by prompt local treatment was soon convalescent. 
Her only child, a boy of six years, was excluded from her companionship 
about one month, after which he was allowed to enter the room, and slept 
in it. Within a few days, namely, thirty-five days after it commenced in 
the mother, the diphtheritic patch appeared upon his fauces. In one of 
the asylums of this city, diphtheria has been prevailing more than a year, 
the cases occurring mainly in one of the buildings, and with so little break 
or intermission that it appears that the diphtheritic virus has not been 
eradicated from one or more of the wards since the first case occurred. 
Such instances show the danger of admitting children into rooms where 
diphtheria has occurred, until a considerable period has elapsed, and 
thorough disinfection has been employed. 

When diphtheria is prevalent, indisposition on the part of a child, and 
especially febrile symptoms, or defluxion from the nostrils, should at once 
arrest attention. Although there is no complaint of soreness of the throat, 
the fauces should be carefully inspected, and if they seem too red, they 
should be sprayed with one of the mixtures recommended above. 

Pertussis. 

Pertussis is an infectious disease attended and manifested by a catarrh 
of the air passages. This catarrh gives rise to a cough which does not 
differ, during the inception and in the declining period, from that in an 
ordinary catarrh, but during the middle period of the malady is spasmodic. 
Exceptionally the system is so mildly affected that the spasmodic element 
of the cough is lacking through the whole course of the malady, or is con- 
fined to a brief period. This distinctive symptom, namely, the peculiar 
cough, has been attributed to the irritating and disturbing action of the 
specific principle on the nerves, which control the muscles of respiration. 
Some attribute it to the impression produced upon the filaments of the 
pneumogastric, especially upon those of the internal branch of the superior 
laryngeal nerve, by the mucus which collects in the larynx and trachea, 
and which is known to contain the contagious principle in abundance. 
This cough consists in a series of forcible and loud expirations, followed 
by a noisy and difficult inspiration. Its special character is due to spas- 
modic contraction of the muscles of expiration, and notably of the small 
muscles of the larynx so as to produce narrowing or even closure of the 
aperture of the glottis. Each paroxysm of the cough usually ends^ not 
ahvays, in the expectoration of viscid mucus. With rare exceptions per- 



causes. 265 

tussis affects the same individual but once. Rilliet and Barthez report a 
case of its second occurrence, and West another case. I have attended 
two adult patients, both women of intelligence, who stated that they had 
had previous attacks in early life. Pertussis usually prevails as an epi- 
demic, but is occasionally sporadic, at which time its type is mild. It is 
highly contagious through the breath of the patient, or from exhalations 
from his surface. 

Age Most cases of pertussis occur between the ages of one year and 

eight years, but it occasionally occurs in adult and even old people who 
have not been attacked previously. It is rare under the age of three 
months, but through the kindness of Dr. Ewing, of New York, I was 
enabled to see a new-born infant with pertussis, whose mother had had 
the disease during the two months preceding her confinement. This infant 
when fifteen minutes old, and during the washing, had the first convulsive 
seizure, which appeared to consist chiefly of a spasm of the laryngeal mus- 
cles, with temporary suspension of the respiration, and attended by deep 
lividity of the features, with some frothing of the mouth. These attacks 
occurred nearly every hour, with intervals of complete cessation of symp- 
toms. The mucus between the lips finally became stained with blood, and 
death occurred on the third day. The mother, the intelligent wife of a 
clergyman, believes that the infant had similar attacks before its birth. 
A parallel case is related by Rilliet and Barthez. 

Causes. — Climate, race, and nationality do not seem to exert any 
decided influence on the spread of pertussis. Females are somewhat more 
liable to be attacked than males, and, as we have seen, a large majority 
of the cases occur between the ages of one and ten years. The nature of 
the contagious principle of this disease has, in my opinion, thus far eluded 
detection, and is likely to, for some time to come, on account of its sub- 
tlety. The last ten years have been characterized by very active search, 
chiefly with the microscope, for the contagia of the infectious diseases. 
Many suppose that it had been discovered, as regards diphtheria, in the 
countless bacteria which swarm in the pseudo-membrane, and even in the 
tissues and excretions during the course of this dreadful disease, mistaking 
an effect for a cause. And Letzerich, about the year 1870, supposed he 
had discovered the cause of pertussis in a fungus, which received upon the 
surface of the air passages in inspiration, increase rapidly and produce the 
spasmodic cough by their irritating effect, or the irritating property which 
they impart to the mucus. In the first stage of pertussis he found only 
the spores of the fungus, and at a more advanced stage in addition to the 
spores he discovered the irregularly ramifying branches of the thallus. He 
introduced the mucus upon the fauces of the rabbit, and witnessed the 
production of pertussis in this animal. But a moment's thought shows us 
that this theory fails to explain the history and phenomena of this disease, 
for, unless the cause were something more subtle than the spores and 



266 PERTUSSIS. 

branches of a fungus, we do not see how it is possible that the mother, 
contracting pertussis during the last weeks of her pregnancy, should infect 
her foetus, whose circulation is entirely distinct ; nor does this theory 
comport with the fact that pertussis passes through regular stages and 
declines, without any measures which are calculated to destroy the fungus. 
Besides, it is stated by Steflfen, in Ziemssen's Encyclopedia, that other 
microscopists have failed to verify the theory of Letzerich. 

Lesions have been discovered in certain fatal cases which have been 
supposed to throw light on the etiology of pertussis, but which are now 
known to have been merely coincidences or results of the disease. Such 
are congestion of the spinal cord and its meninges, hyperemia of the pneu- 
mogastrics, and tumefaction of the tracheo-bronchial glands, which it was 
claimed produced the spasmodic cough by compressing the recurrent laryn- 
geal nerve. 

Pathological Anatomy. — Catarrhal inflammation of the air passages 
is uniformly present. It occasionally occurs on the mucous surface of the 
nostrils and pharynx, but is often absent from these parts. In the ma- 
jority of cases the inflammation affects the surface of the glottis and that 
below the glottis. However, in not a few cases the surface of the larynx 
and trachea is pale and not swollen, or the inflammatory appearance is 
limited to a small part, as the ventricles of the larynx, w T hile the mucous 
coat of the bronchi and their branches is swollen and red, and covered 
with tenacious mucus. Sometimes certain alveoli are found distended by 
a thick muco-pus, producing an appearance like minute tubercles. 

A common lesion found in the lungs of those who have perished with 
this malady is emphysema, affecting chiefly the peripheral portions of 
the upper lobes. It is commonly vesicular emphysema occurring from 
over-distension of the air cells, but in some instances the air has escaped 
into the connective tissue, causing interstitial emphysema. According to 
my recollection of fatal cases, which have occurred from time to time in the 
institutions of New York, and of which I have made post-mortem examina- 
tions, the upper lobes were exsanguine and inflated to nearly the fullest 
extent possible within the thorax, while other portions of the lungs pre- 
sented areas of pneumonic, or more or less complete atelectatic solidifica- 
tion. Pneumonia, atelectasis, and small extravasations of blood in the lungs, 
are, indeed, common lesions. Hyperplasia of the bronchial glands is also 
common, and hyperplasia has also been occasionally observed of other 
lymphatic glands, as the mesenteric. An ulcer under the tongue which 
observers have frequently noticed is now attributed to pressure of the 
tongue on the lower incisors during the cough. 

In fatal cases small extravasations of blood in or upon the brain are 
common, as is also passive congestion of the sinuses, veins, and capillaries, 
meningeal and cerebral, attended with more or less transudation of serum 
within the ventricles of the brain, and between the meninges. Large dark 



SYMPTOMS. 267 

and soft clots, and occasionally some that are white or yellow, are common 
in the intra-cranial sinuses, especially if, as often happens, death has oc- 
curred in convulsions, which supervened upon the severe spasmodic cough. 

Symptoms. — Pertussis consists of three stages : first, that of catarrh of 
the air passages ; secondly, the stage of spasmodic cough, or for brevity 
the spasmodic stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and bron- 
chitis, which present nothing peculiar, or different from ordinary catarrhs 
of the same parts, unless occasionally the cough is more frequent and 
teasing. Trousseau has known it to be repeated forty or fifty times per 
minute. The eyes present a moderately suffused appearance, and there is 
sneezing, with defluxion from the nostrils, but less than in the commence- 
ment of measles. The cough, which commences as soon as the catarrh 
affects the larynx is accompanied by little or no expectoration. The pulse 
and respiration are moderately accelerated, and such other symptoms, as 
commonly accompany catarrh of a mild grade are present, namely, in- 
creased heat of surface, thirst, and impaired appetite. 

The duration of the first stage varies in different cases. In severe 
hooping-cough it may last only two or three days, and in mild cases, be 
protracted to five or six weeks. It may be absent especially in very young 
infants. We have alluded above to the new-born infant, in whom there 
was no first stage, a glottic spasm occurring soon after birth. The first 
stage commonly ends in from eight to fifteen days. In fifty-five cases ob- 
served by Dr. West its average duration was twelve days and seven-tenths 
of a day. It is stated above that the first stage in rare instances continues 
during the entire course of pertussis ; at least no spasmodic cough occurs. In 
two such cases which I now recall to mind, both girls, the inflammatory 
symptoms abated somewhat after the first few days, and there remained an 
occasional easy cough like that of simple bronchitis, Avhich continued 
during a period corresponding with the ordinary duration of pertussis. The 
diagnosis would have been doubtful, except for the occurrence of pertussis 
with its regular stages, in other children of the same families. 

Second Period. — This may commence quite abruptly, but ordinarily its 
beginning is gradual. While the cough commonly has the character pre- 
sent in the first stage, it is now and then observed to be more severe and 
spasmodic, especially at night, and when the patient is in any way excited. 
The spasmodic element increases, so that in the course of a week all doubt 
as to the nature of the disease is removed. 

The severity of the cough in the second stage varies considerably in 
different cases. It sometimes commences quite abruptly, with little warn- 
ing, but commonly there is premonition of it, and the child endeavors to 
repress it. He experiences a tickling sensation in the throat, or median 
line of the chest, or a feeling of constriction. He leaves his playthings, 
and rests his head on his mother's lap, or takes hold of some firm object 
for support ; his face has a grave or even anxious appearance, while the 



268 PERTUSSIS. 

pulse and respiration are somewhat accelerated. Immediately the cough 
begins. It consists in a series of short and hurried expirations, which 
expel a large part of the air contained in the lungs, followed by a hurried 
inspiration, which is difficult and noisy on account of the spasmodic con- 
traction of the laryngeal muscles, and narrowing of the glottic aperture. 
The sound which accompanies the inspiration, and which is often absent 
especially in infants, is designated the hoop. The forcible expirations, 
and difficulty experienced in expelling the air from the lungs on account 
of the constriction of the glottis afford explanation of the emphysematous 
distension of the air cells in the upper lobes, which w r e have seen is so 
common in severe pertussis. 

There may be a single series of expirations terminating in the man- 
ner stated, but often there are several such series embraced in a paroxysm. 
The cough commonly ends in the expulsion of frothy mucus from the 
bronchial tubes, and sometimes in vomiting. During the cough there is 
temporary arrest of blood in the lungs, leading to congestion in the right 
cavities of the heart, and throughout the systemic circulation ; therefore 
the face is flushed and swollen, and occasionally hemorrhage occurs under 
the conjunctiva, or from one of the mucous surfaces. The most frequent 
hemorrhage is epistaxis. When the cough ceases, and normal respiration 
is restored, the fulness of the vessels immediately abates ; but often puffi- 
ness of the features is observed, due to serous infiltration of the subcuta- 
neous connective tissue, and continuing for days or weeks during the 
period when the cough is most severe. The paroxysm lasts from a quarter 
to a half or even a whole minute, and in that time, in cases of ordinary 
severity, there are often as many as fifteen to twenty series of expirations. 

At the close of the paroxysm, if there is no complication, the symptoms 
soon abate ; the temperature, pulse, and respiration become normal, and 
there is no evidence of disease. The cough in the second stage is much 
more frequent in one case than another. At the height of this stage it is 
generally more severe if it occurs at long intervals than when frequent. 
During the weeks in which pertussis is most severe, there is, in the average, 
about one paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second stage, 
or the thirtieth to thirty -fifth day of the disease, after which it remains 
stationary for a certain time. It is apt to be more frequent in the night 
than daytime. Sometimes it occurs while the child is quiet ; it may even 
awaken him from sleep, but it is often also produced by mental excitement 
or by physical exertion. Anger or fright gives rise to it, and therefore the 
child is apt to cough when being examined by the physician, or when his 
wishes are not complied with. The ordinary duration of the second stage 
is from thirty to sixty days. It may, however, be considerably longer or 
shorter than this. 

The third stage, which commences at the time when the spasmodic cough 
begins to abate, is short, not continuing longer than two or three weeks. 



COMPLICATIONS. 269 

A protracted stage of decline indicates some complication. While the 
sputum in the second stage is mucous and frothy, that in the third stage is 
more opaque and puriform. 

In the third as in the second stage, if there is no complication, the pulse 
and respiration in the intervals of the paroxysms are nearly or quite nat- 
ural. Febrile excitement may, however, now and then occur from trifling 
causes, or, indeed, without any apparent cause. The digestion and the 
general health in uncomplicated pertusses remain unimpaired, with the 
exception of more or less emaciation, which is apt to occur in all but the 
mildest cases, in consequence of the frequent vomiting. After complete 
recovery, it is not unusual for the spasmodic cough to reappear, at times, 
for one or even two years. The cough of ordinary simple laryngitis, or 
bronchitis, assumes this character. 

Complications. — These, like the symptoms, are chiefly of a twofold 
character, namely, inflammatory and neuropathic. From the nature of 
the cough in pertussis, it would naturally be supposed that that spasmodic 
affection, which is now designated internal convulsions, and which is char- 
acterized by spasm of certain muscles of respiration, would be a frequent 
complication. It does sometimes occur in young children, but it is not 
common. Clonic convulsions affecting the external muscles are, on the 
other hand, not infrequent. They occur chiefly in the second stage, when 
the cough is most severe, and in infancy much more frequently than in 
childhood. They are apt to be general and severe, or, if not of this char- 
acter at first, to become such. The convulsions commence, in most in- 
stances, in or directly after the paroxysm of coughing ; but they sometimes 
occur in the interval when the child is quiet. 

Rilliet and Barthez remark : " Almost all infants succumb to this com- 
plication, ordinarily in the twenty-four hours which follow the first 
attack ; nevertheless, life may be prolonged during two or three days." 
(Article Coqueluche.) In my own practice, this complication usually ended 
fatally before bromide of potassium and chloral were employed, but with 
the proper use of these agents can often be arrested. In the month of 
June, 1867, I was attending a little girl two years and four months 
old, who had reached the fifth week of pertussis, when she was seized 
with general clonic convulsions. The mother, who was requested to keep 
a record of the number of convulsions, stated that there were twenty 
in all, occurring within forty-eight hours. They affected both sides, 
the shortest lasting only three or four minutes, the longest seventy-five 
minutes. The treatment in this case, which eventuated favorably, will 
be noticed hereafter. 

In those who die of convulsions occurring in hooping-cough, the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due in part to the cough which 
precedes the convulsions and in part to the convulsions themselves. At 



270 PERT.USSIS. 

the autopsies which I have made of two infants, who died in hospital 
practice from hooping-cough, accompanied by convulsions, all the cerebral 
sinuses were filled with clots, which were generally soft and dark ; but in 
the lateral sinuses clots were found which were light-colored. The light 
color of a clot, either in a vein or sinus, indicates its ante-mortem formation. 

The gravity of the convulsive attack can be ascertained by observing 
whether the patient readily recovers consciousness. Its return indicates 
that there is no serious congestion. On the other hand, great drowsiness 
remaining, or a semi-comatose state, indicates persistent congestion and, 
perhaps, even the formation of clots in the sinuses of the brain. Death 
from convulsions is usually preceded by coma. Occasionally meningeal 
apoplexy supervenes upon the congestion, and death is immediate. 

The most frequent inflammatory complications are bronchitis. and pneu- 
monitis. Inflammation of the bronchial tubes of a mild grade we have 
seen, is a common accompaniment of pertussis, but when it extends to the 
minuter tubes, or becomes so severe as to cause acceleration of respira- 
tion, it is, properly, a complication. Both bronchitis and pneumonitis, 
occurring as complications, are developed, with few exceptions, in the 
second stage. Bronchitis is accompanied by accelerated respiration and 
pulse, and increased temperature. The danger is proportionate to the 
amount of dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it 
occurs more frequently in pertussis than in any other constitutional affec- 
tion of early life, excepting measles. The congestion, which occurs and 
remains in the lung when the cough is frequent and severe, favors the 
development of pneumonia. The symptoms and physical signs which 
accompany this inflammation and serve for its diagnosis are the same as 
in the primary form of the disease, and are described elsewhere. Bron- 
chitis or pneumonia usually moderates the severity of the spasmodic 
cough, for when the inflammatory element in pertussis increases, the 
spasmodic abates. On the abatement of the inflammation, however, the 
cough usually regains its former convulsive character. The fact may be 
stated in this connection, that any complication or intercurrent disease, 
which is attended by decided febrile reaction, ordinarily renders the cough 
for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated 
temperature, acceleration of pulse and respiration, short and frequent 
couch. These symptoms do not cease as long as the inflammation con- 
tinues, whereas in uncomplicated pertussis the patient seems nearly or 
quite well between the coughs. In pneumonia the respiration is accom- 
panied by the expiratory moan, and in both bronchitis and pneumonia 
there is more or less depression of the infra-mammary region during in- 
spiration. These symptoms, in connection with the physical signs, render 
diagnosis in most instances easy. Although the general character of the 



COMPLICATIONS. 271 

cough is changed, a cough now and then occurs, even when the inflamma- 
tion is pretty severe, sufficiently spasmodic to indicate the nature of the 
primary affection. Capillary bronchitis and pneumonia are always serious 
complications. 

Not only is more or less emphysema a common complication of severe 
pertussis, but bronchiectasis also occurs in certain cases, due to the same 
conditions. Emphysema is a common lesion in young and feeble infants, 
even when there is no history of any previous severe disease of the respira- 
tory organs. I have found it one of the most common lesions in infants of 
feeble constitutions, who die in the hospitals and asylums of New York, 
but it is apt to be interstitial and confined to a small part of the upper 
lobes. It is not accompanied by that general distension of the alveoli and 
consequent enlargement of the lobes, which occur in the emphysema of 
pertussis. Its chief cause in these feeble and wasted infants appears to 
be impaired nutrition and change in the molecular condition of the pul- 
monary tissue. The same condition often occurs in severe and protracted 
pertussis, and therefore serves as an additional and efficient cause of the 
emphysema. 

The following was a not unusual case of this disease as it occurs in 
the tenement houses and asylums of New York. At the meeting of the 
New York Pathological Society, October 14th, 1868, I exhibited em- 
physematous lungs, removed from an infant who died at the age of nine- 
teen months, at the commencement of the fourth week of pertussis. Death 
occurred from thrombosis in the lateral sinuses of the cranium, resulting 
from the severe spasmodic cough, eclampsia, and feebleness of the circula- 
tion, as the infant was previously in a reduced state from chronic entero- 
colitis. At the autopsy the superior lobes of both lungs were found 
exsanguine, doughy to the feel, and enlarged so as to rise above the level 
of the other lobes. The resiliency and elasticity of the lung tissue in 
these lobes were evidently greatly impaired, and their air cells in a state 
of over-distension. The other lobes were healthy except that one of them 
was the seat of catarrhal pneumonia. In this case there had been no 
disease affecting the respiratory apparatus previously to the pertussis, so 
that the incipient vesicular emphysema was referable to the severe cough 
and impaired nutrition of the lungs. 

Occasionally we meet cases of severe pertussis in which, while there is 
over-distension of the alveoli of the upper lobes, collapse occurs over a 
greater or less extent of the lower lobes. Collapse like emphysema may 
continue for weeks or months subsequently to pertussis, and then gradu- 
ally disappear, but in the following rare case in my experience, it was 
permanent. John O'Neil, aged 5-J- years, was brought to the Bureau for 
the Relief of the Out-door Poor in New York, in December, 1876. He 
lived in the under-ground basement of a tenement house, and was supported 
by charity, except, at intervals, when his father, who was dissipated, 



272 



PERTUSSIS 



could obtain work. At the age of fifteen months he had a glandular 
swelling on the right side of the neck, which suppurated, and three months 
later one on the opposite side, which also suppurated. At the age of 2\ 
years he had bronchitis, the cough of which did not abate till two months 
subsequently. When near the age of three years he had measles, and the 
cougli from this disease lasted three or four months. In the summer of 
1875, or about one year subsequently to the measles, he contracted per- 



Fig. 14. 



ment. It lasted four months, never, however, confining him to bed or 
materially impairing his appetite ; and one morning about the close of the 
second month of the malady, the parents first observed depression of the 
right side of the thorax. This gradually increased for a few weeks and 
has been permanent. The parents stated that he had never been confined 
to the house or without appetite except during the week of measles. 

Since his recovery from pertussis he has had his usual appetite and 
general health, but crying or excitement commonly brings on a pretty 
severe cough. The depression of the thorax examined in front, begins 
quite abruptly in the line of the left costo-chondral articulations. Circum- 
ferential measurement of the left side from the middle of the sternum to 
the spine, the tape lying a little below the nipple gives eleven and a half 

inches, while corresponding measurement of 
the right side, gives seven and a half inches ; 
pulse 136, sounds of the heart normal; respi- 
ration 44. On auscultation over the right side 
of the chest we observed bronchial respiration, 
and a feeble bronchophony, with perhaps slight 
vocal fremitus. The accompanying figure is 
from a photograph by Mr. Mason, photo- 
grapher to Bellevue Hospital. My first im- 
pression on observing this case was that it was 
one of unexpanded lung, which had been com- 
pressed by a pleuritic effusion, but it is seen 
that the history points clearly to pertussis as 
the cause of the deformity. The depression 
occurred somewhat suddenly wiien the cough 
was most severe, and when there was no fever, 
loss of appetite, or other symptoms of pleuritis. 
The patient had not presented any marked 
evidence of rachitis, but was decidedly stru- 
mous. 

Pertussis is sometimes complicated by the 

eruptive fevers. There does indeed seem to 

be some affinity between it and measles, so that many epidemics of the 

two have been observed at about the same time. During my term of ser- 




DIAGNOSIS. 216 

vice in the New York Foundling Asylum, in May, 1878, measles and 
pertussis prevailed in the wards at the same time. Eighteen of the chil- 
dren, who were having pertussis, contracted measles, and the Sisters, 
who were very intelligent and faithful observers, and were requested by 
me to notice the effect of the complication, stated that with few exceptions 
the severity of the hooping-cough was increased during the continuance 
of the exanthem. This is contrary to the statement of some authors. 

Diagnosis During the period of invasion it is impossible to diagnos- 
ticate pertussis. Its nature can only be conjectured from a known ex- 
posure, or from the epidemic occurrence of the disease. In the second 
stage, which is characterized by the spasmodic cough, diagnosis is ordi- 
narily easy, and often the parents are able to announce the nature of the 
disease when the physician is called. Still, a mistake is sometimes made : 
a spasmodic cough very similar to that of pertussis occasionally occurs in 
other maladies. Young infants with bronchitis frequently experience 
great difficulty in the expectoration of mucus, which collects in the air- 
passages and provokes a suffocative cough. The following facts will aid 
in making the diagnosis. Bronchitis, accompanied by a suffocative cough, 
is an acute disease, and the cough occurs at an early period, usually in the 
first week. It lacks the inspiratory sound or the hoop, and is associated 
with constantly accelerated respiration and well-marked febrile symptoms, 
dependent on the inflammation. Moreover, the cough is only occasionally 
suffocative, according to the amount of mucus in the tubes. The spas- 
modic cough of pertussis, on the other hand, is preceded by the stage of 
invasion, and this cough occurs only in the second stage, when the febrile 
symptoms have abated. Again, the suffocative cough of bronchitis rarely 
ends in vomiting, which has been seen to be so common in the cough of 
pertussis. 

The only other disease with which there is much likelihood of confound- 
ing pertussis is bronchial phthisis. The points of differential diagnosis are 
the following : the one epidemic, and spreading by contagion ; the other 
non-contagious and isolated : the one embraced in three distinct stages, 
and much shorter ; the other chronic, and presenting no stages, but com- 
mencing with mild non-febrile symptoms, and progressively becoming 
more severe : in the one an absence of symptoms in the intervals of the 
cough, provided there is no complication ; in the other constant symptoms, 
such as are common in tubercular disease. The previous health, and the 
presence or absence of a tubercular cachexia, should be considered in de- 
termining the nature of the disease, and usually, in bronchial phthisis, the 
lungs are also affected, so that auscultation and percussion may furnish 
positive proof of the nature of the cough. 

The attacks of suffocative cough, which are produced by the lodgment 
of a foreign body in the larynx, or lower down in the air passages, bear a 
close resemblance to those of pertussis. The diagnosis can be made by 
18 



274 PERTUSSIS. 

the history, for in the one case there is a preliminary catarrhal stage, and 
in the other the cough begins abruptly, and usually after the known swal- 
lowing of the offending substance, which produces dyspnoea and a spas- 
modic cough as soon as it enters the larynx. The presence of the body 
can also be determined in a large proportion of cases by the laryngoscope 
and auscultation. 

Prognosis — A larger proportion doubtless recover under the better 
therapeutics of the present time than in former years. According to 
Hirsch (II., p. 105) 72,000 persons perished from this disease in England 
and Wales between 1848 and 1855, or one in every forty who died; and 
Wilde's reports show that it stands fifth as regards mortality among the 
epidemic diseases of Ireland. In New York city during the half century 
ending with 1853, 4840 died of pertussis, or one died from this disease in 
every 76 of deaths from all causes. 

As a rule, the older the child the better the prognosis. Young infants 
may die of suffocation due to the glottic spasm. Eclampsia with extreme 
passive congestion of the encephalon is a not infrequent complication in 
children under the age of five years, and it is apt to terminate fatally. 
It may, however, in my opinion, be averted in most cases by proper 
treatment. In rare instances death may occur in or immediately after a 
paroxysm of coughing, in consequence of the rupture of cerebral or men- 
ingeal capillaries, and the effusion of blood, or from stasis and coagulation 
of blood in the venous system, especially if convulsions have supervened 
upon frequent and protracted paroxysms of coughing. Other complica- 
tions, which are likely to arise under conditions which favor their devel- 
opment, and which greatly increase the danger and render the prognosis 
unfavorable, are capillary bronchitis, pneumonia, diphtheria, and in the 
summer season intestinal catarrh. In New York I have noticed that 
pertussis occurring in the summer is much more fatal if it becomes com- 
plicated with the intestinal catarrh which is an epidemic among infants 
during that season. 

Feebleness of system and antecedent and accompanying chronic dis- 
ease increase the danger. Pertussis sometimes produces so much ema- 
ciation and loss of strength, in consequence of the severity and frequency 
of the cough, and the repeated vomiting, that intercurrent diseases which 
in favorable states of the system would probably end in recovery, are very 
apt to prove fatal. 

I usually inform the family that the patient is doing well, if he seem 
entirely well between the paroxysms, but if he appear ill, whether with 
somnolence, fretfulness, fever, loss of appetite, accelerated breathing, or 
diarrhoea, he is not doing well, and probably has some complication, which 
requires immediate attention. Sudden deaths occur in the second stage ; 
but deaths from causes or conditions which operate in a gradual and pro- 
tracted manner, may occur in the second or third stage. 



TREATMENT. 275 

Treatment In the catarrhal stage the treatment should be the same 

as in mild idiopathic catarrh. Demulcent and gentle expectorant meas- 
ures are required. Care should be taken to employ nothing which re- 
duces the strength or impairs the general health. If there is much 
bronchitis with accelerated breathing and frequent cough, mild counter- 
irritation to the chest, and the use of the oil silk jacket are proper. 

Therapeutic measures are chiefly indicated in the second stage, or that 
of convulsive cough. Proper treatment may control the severity of the 
cough, and abridge the duration of the second stage, and prevent or con- 
trol complications. As with most other diseases whose cause and nature 
are obscure, and which under ordinary circumstances terminate favorably, 
pertussis has received a great variety of treatment. The enumeration of 
the medicines, and modes of treatment which have had their season of 
repute, and been employed by intelligent physicians, would occupy too 
much time. The treatment should vary in some respects according to the 
case, but a small number of medicines suffices, even in the most severe 
and obstinate forms of the malady. Those which I have found most use- 
ful for internal treatment, and which are employed more than any others 
in the institutions of Xew York, are belladonna, quinine, the bromides, 
and hydrate of chloral. They are now largely used in the treatment of 
pertussis in this city, and I can bear witness that a larger number of cases 
treated by them escape complications and recover, than under other modes 
of treatment which were formerly employed. 

When the second stage commences, belladonna should be given in ordi- 
nary cases in morning and evening doses. Children require a larger pro- 
portionate dose than adults, and it can with few exceptions be safely ad- 
ministered even to the youngest infant in a quantity gradually increased 
till the cough is moderated or physiological effects are produced. The 
physiological effects are more readily produced in some than in others. 
Thus recently I gradually increased the doses of the tincture of belladonna 
to twelve drops for a child aged three and a half years, who had severe 
pertussis, without producing the characteristic efflorescence, while smaller 
doses from the same bottle produced this effect in older children. Probably 
the action of the drug is on the respiratory centres in the inedulla, and 
not directly on the muscles, as once held. Rarely I have discontinued the 
belladonna on account of diminished flow of urine, which this agent may 
or may not have produced, and very rarely on account of suddenly 
developed muscular weakness, Avhich I had reason to think the belladonna 
caused. This occurred in the case alluded to above, in which twelve 
drops of the tincture were given, so that the muscles seemed flabby, and 
the trunk and head were supported with difficulty. 

Trousseau sometimes employed atropia in place of belladonna, since 
the medicinal property of the plant resides in this alkaloid, which being 
crystalline has uniform strength. He gave the neutral sulphate of atropia 



276 PERTUSSIS. 

in doses of about y A ¥ part of a grain, dissolved in distilled water, to in- 
fants or young children. He gave the medicine twice each day, and for 
older children ordered a proportionately larger dose. Brown-Sequard, in 
remarks made before the United States Medical Association in May, 1866, 
maintained that the duration of pertussis, so far as its neuropathic ele- 
ment is concerned, might be abridged to a few days, by doses of atropia, 
sufficiently large to produce toxical effects. He recommended a dose which 
will cause, and repeated will maintain delirium for three days, after which 
he stated that the cough is no longer spasmodic. But a more moderate 
dose, even with a longer time to effect a cure, seems preferable. The 
tincture of belladonna is most convenient for use, and most of that kept 
in the shops is active and reliable. The doses which I have ordinarily 
found to be sufficient, and which also produced efflorescence, were as fol- 
lows : to a child of two years three drops, and to one of six or eight years, 
eight or ten drops, morning and evening. I always, however, commence 
with a smaller number, and continue to administer the dose which produces 
the local effects alluded to, unless the cough is moderated with smaller 
doses. In the majority of cases I have noticed no decided effect till the 
rash was produced, when the symptoms improved, the cough becoming 
less frequent or less severe. By the belladonna treatment the spasmodic 
stage may not only be rendered mild, but abridged to two or three weeks. 
In some cases the severe cough begins to yield almost immediately under 
full doses of this agent, but in other cases its continuance for some clays 
is necessary, with other remedies as adjuvants, before there is any appre- 
ciable benefit from its use. 

The use of quinine as a remedy for pertussis was first strongly recom- 
mended by Binz, who embraced the theory of Letzerich, that this disease 
is produced by a fungus, upon which the quinine acts injuriously. I have 
not observed that improvement from the use of this agent, when employed 
alone — and it has been largely prescribed in the institutions of New 
York — which I have observed in cases treated at the same time, with 
morning and evening doses of belladonna. Its good effects upon the spas- 
modic cough are probably due to the fact, that it diminishes reflex irrita- 
bility (Schlakow and Eulenberg). At the same time it acts as a tonic, 
and improves the appetite, and tends to prevent any depressing effect 
which might occur from the belladonna. It is beyond question the proper 
remedy in those frequent cases, in which febrile symptoms arise, whether 
from some complication as bronchitis, pneumonia, or other causes. In 
ordinary cases a child of five years should take about two grains four times 
daily, in the elixir adjuvans or other convenient vehicle. As an antipy- 
retic a larger dose may sometimes be needed. 

As the paroxysms are apt to be more severe at night, and the patient 
consequently be deprived of the required sleep, a medicine is indicated, 
which will procure some hours of rest, and thereby diminish the number 



TREATMENT. 277 

of paroxysms. For this purpose the hydrate of chloral is especially useful 
given in doses of two to five grains according to the age, and perhaps re- 
peated. It does not seem to me that chloral exerts any marked influence 
upon the cough ; it seems to be useful chiefly in the manner stated, namely, 
by procuring prolonged sleep. 

One of the chief dangers from pertussis we have seen to be the occur- 
rence of great passive congestion of organs, especially of the brain, with 
the liability to hemorrhages, serous effusion, and eclampsia. This is in 
great part prevented by the action of the medicines mentioned above, 
which diminish the severity of the cough, or its frequency. But when 
there are great and frequent congestions of the nervous centres, producing 
eclampsia or premonitions of eclampsia, the use of one of the bromine 
compounds is indicated for its prompt and decided action in averting the 
danger. Even if the symptoms are not urgent, its tranquillizing effect, and 
especially its prompt action in diminishing reflex irritability, render it 
one of the most useful agents in pertussis. If there is sudden twitching of 
the muscles, marked stupor, headache, or fretfulness, or adduction of the 
thumbs across the palms of the hands during the cough, I never fail to 
give the bromide of potassium in sufficiently large and frequent doses, and 
now eclampsia occurs much more rarely in a case which I treat from the 
commencement, than in former years. 

Inhalations have been much employed, and from the nature of pertussis 
we would suppose that proper substances used in this way would materially 
aid in the treatment. The inhalation of the fumes from the purifying of 
gas has been employed for several years as one of the methods for allevi- 
ating the cough, and there is sufficient statistical evidence of its utility. 
But since the atomizer has come into general use this instrument renders 
other and more inconvenient methods of employing vapors unnecessary, 
carbolic acid produces an anaesthetic effect on the mucous surfaces, and its 
vapor has been used by Dr. Burchardt of Berlin, and others, in the treat- 
ment of hooping-cough with apparently good results. Opium and glycerine 
inhalations appear also to be useful. If therefore the internal remedies 
recommended above do not sufficiently relieve the cough some such mix- 
ture as the following should be employed every two to six hours either 
with the hand or steam atomizer. If the hand atomizer is employed the 
bulb should not be compressed more than six to twelve times at each using. 

I£. Acid, carbolic, gtt. xxiv ; 
Aq. extract, opii, gr. v ; 
Glycerinse, 3-iij ; 
Aqua?, §v. Misce. 

The complications of pertussis require prompt treatment. TVhenever the 
child feels ill between the paroxyms, he should be carefully examined, and 
some complication will probably be found which requires treatment. If 
the bronchitis have increased so as to become a complication, or pneumonia 
have arisen, the whole chest should be covered with a light flaxseed poul- 



278 PAROTIDITIS. 

tice containing one-sixteenth part of mustard, while quinine and ammonia 
with alcoholic stimulants are given at regular intervals. Cerebral acci- 
dents are best arrested by the warm foot bath, cold to the head, and by 
the bromide and chloral. 

Diphtheria not infrequently supervenes as a complication in a locality 
where it is endemic or epidemic, and if mild is apt to be overlooked. Re- 
cently I have seen a case in which diphtheria complicating pertussis had 
continued four days, without being recognized by the attending physician, 
the symptoms being attributed to other causes. The diphtheritic patch 
in these cases is apt to appear upon the well-known sore under the tongue, 
in addition to its occurrence upon other parts. This secondary form of 
diphtheria requires the same treatment as the primary form. 

Hauke, in 1862, published experiments which showed that both car- 
bonic acid and ammoniacal vapors when inhaled increase the cough, 
while the inhalation of oxygen produced no cough and was agreeable to 
the patient. Hence children in close and crowded apartments suffer most 
severely from pertussis, and those who are taken to parks, or the country, 
where vegetation absorbs the carbonic acid, not only obtain benefit from 
the general invigorating influence, but also as regards the cough. The 
fact that fresh and pure air benefits the cough has indeed long been 
known, and has influenced practice, for patients are almost universally 
allowed to be much of the time in the open air, and are taken to the parks 
and upon excursions. Nevertheless caution in this regard is required, for 
exposure in wet weather or to sudden changes of temperature is very apt to 
develop bronchitis or pneumonia. 

Prophylaxis Pertussis is very contagious, and it appears to be, in 

nearly all instances, if not in all, contracted by inhaling the breath of the 
patient. I have never observed a case in which it seemed to be commu- 
nicated through a third person, and it is not, I think, usually contracted 
by children living in the same house, if there is no personal contact. 
There is not, therefore, that urgent need of disinfection, and of caution on 
the part of physician and nurse in their subsequent intercourse with 
healthy children, as in case of the eruptive fevers. 



CHAPTER II. 

PAROTIDITIS. 

Ordinarily, parotiditis, or parotitis, or mumps, has no premonitory 
stage ; but in exceptional cases languor with fever precedes the disease for 
a few hours. Mumps commences with tenderness in the parotid region, 
followed soon after by tumefaction. The swelling gradually increases ; it 



NATURE. 279 

fills the depression under the ear, extends forward and upward upon the 
cheek, and downward to a greater or less extent upon the neck. It has 
been demonstrated in case of symptomatic parotiditis, and the same is 
probably true of the idiopathic disease, or mumps (Virchow), that the 
swelling is due to inflammation of the gland-ducts and consequent oedema 
of the interstitial tissue. The inflammation is specific, due to a materies 
morbi in the blood, and hence its decline after a fixed period. It reaches 
its maximum from the third to the sixth day. The most prominent point 
at this time is immediately underneath the lobule of the ear. The tumor, 
which is firm but slightly elastic, presses outward the lobule. In most 
cases the skin preserves its normal appearance over the swelling, but oc- 
casionally it presents a faint blush. The pressure which movements of 
the jaw produce on the gland renders mastication and even talking pain- 
ful. Febrile movement more or less intense occurs, lasting, in ordinary 
cases, not more than forty-eight hours, but occasionally it is more pro- 
tracted. Vomiting and epistaxis are sometimes present. The swelling 
having attained its maximum size, remains stationary a short time, when 
it begins to decline, and by the sixth to tenth day it has entirely subsided. 

In most cases parotiditis is double ; it commences on one side, more 
frequently the left than right, and in from one to four days the opposite 
gland is involved. In those exceptional cases in which only one parotid 
is affected, the opposite gland may be the seat of the disease at some sub- 
sequent period. It has been estimated that the proportion of unilateral 
to double mumps is as one to ten. 

The total duration of this disease is usually from eight to ten days ; in 
the mildest cases it may not be more than five days. The submaxillary 
glands are often involved in connection with the parotids, and sometimes 
also the sublingual, although, from their small size and concealed position, 
their tumefaction escapes notice. Rarely the tonsils are also tumefied. 
Sometimes free perspiration occurs at the commencement of convalescence. 

The swelling of the parotids sometimes abates suddenly, and in the 
male the testicle, epididymis, and tunica vaginalis become inflamed; 
while in the female the mammary glands, ovaries, or the labia majora, 
are the seat of the so-called metastasis. Occasionally these inflammations, 
which are less frequent in young children than those near the age of 
puberty, when the sexual organs are becoming more developed, occur 
without subsidence of the parotid swelling. They cause considerable 
increase in the fever and constitutional disturbance, but with proper 
treatment decline in six to eight days, pursuing the same course as the 
parotid inflammation. 

Nature Parotiditis is contagious. It is rare in infancy and after 

the middle period of life, occurring chiefly in childhood, youth, and early 
manhood. An incubative period of about twelve days was ascertained by 
me in cases occurring in the Protestant Episcopal Orphan Asylum of this 



280 PAKOTIDITIS. 

city. The observations of others give a similar result. Parotiditis is a 
blood disease, having the local manifestation described above, and which 
is our. only means of diagnosis. 

Diagnosis -If the physician has seen but few cases of mumps there is 

danger that he may mistake the swelling for an inflamed cervical gland, 
or vice versa, but an inflamed cervical gland presents to the finger a hard- 
ness almost like that of cartilage, and it is circumscribed or round, and 
does not invest the ear. These characteristics contrast with the elasticity, 
seat, and shape of the parotid swelling, which extends forward on the 
cheek and surrounds and elevates the lobule of the ear. Tumefaction 
resulting from diphtheritic or any other form of faucial inflammation, or 
from periostitis affecting the root of the posterior molar, may be detected 
by examining the fauces and interior of the mouth. 

Treatment. — This is very simple. Oakum or carded wool may be 
bound over the swelling, and the surface occasionally rubbed with sweet 
oil. Mild laxative and diaphoretic drinks, such as bitartrate of potash or 
lemonade, are useful. If metastasis occur, the new local affection should 
receive chief attention. It should be treated in the same manner as if it 
occurred independently of the mumps, while emollient poultices or fomen- 
tations should be applied over the parotids. The ill effects of repellant 
applications in mumps are shown by the following case : — 

On March 19, 1877, I was requested to see a young gentleman of eigh- 
teen years. He had been well till March 14th, when he complained of 
pain below his ears, and his mother applied a towel, wrung out of cold 
water, around his neck. On the following day slight swelling was observed 
under the angle of the lower jaw, on the right side (submaxillary gland), 
and the cold application was continued. On the 17th the swelling had 
disappeared, but the fever and headache had greatly increased, so that he 
was compelled to lie in bed. On the 19th, at my first visit, he had such 
violent headache, and was so intolerant of light and noise, that I greatly 
feared that he had acute encephalitis. All swelling under the ears was 
gone ; the left testicle was tender, and beginning to swell ; axillary tem- 
perature 102°. The cold cloths were removed from the neck and applied 
to the head, and potass, bromid. gr. xxv administered every third hour. 
20th. Axillary temperature 104° ; symptoms unabated and alarming. 
Ordered six leeches to be applied upon the temples and left groin, and a 
purgative, and two drops of the tincture of aconite to be given with each 
dose of the bromide. 21st. Temperature 103°. States that numbness 
and a pricking sensation which he had felt in both legs during the last 
forty-eight hours had ceased (possibly from the aconite). 23c?. Is conva- 
lescent. Has no return of the swelling under the ears, and the orchitis 
has abated. 



SECTION IV. 
OTHER GENERAL DISEASES. 



CHAPTER I. 

INTERMITTENT FEVER. 

This is a constitutional malady produced by a miasm which emanates 
from the soil. I have notes of 36 cases of this disease occurring under the 
age of 3-J- years. Several of the cases were treated in private practice, and 
the rest in the institutions with which I have been connected. In children 
above the age of 3J- years intermittent fever differs but little from that of 
the adult, while in those under this age it presents certain peculiarities, 
Of the 36 cases which I have observed, 19 had the quotidian form, 10 the 
tertian, 2 the tertian becoming afterwards quotidian, 1 the quotidian be- 
coming afterwards tertian, while in the remaining 4 cases the form of the 
disease is not stated. In quotidian ague the malaria has been supposed to 
act more powerfully on the system, or the system is more susceptible to its 
influence than in the tertian form, and hence the fact that the quotidian is 
the prevailing type of ague in tropical regions, where vegetation is luxuri- 
ant, marshes extensive, and the heat intense. According to this theory, 
the feeble resisting power in the system of the infant explains the fact that 
it has quotidian more frequently than tertian intermittent, although the 
latter is much more common in the adult in this climate. 

Facts demonstrate that infants sometimes receive intermittent fever from 
their mothers. If mothers during gestation have malarious cachexia, their 
infants, whether born at full time, or, as often happens, prematurely, are 
apt to be small, thin, and feeble, and occasionally they have soon after 
birth distinct paroxysms of the ague. Dr. Stokes related the case of a 
pregnant woman with ague, who believed that she noticed periodical tre- 
mors of her foetus, but I suspect that she was mistaken, as regards the 
cause, for the paroxysm of intermittent in young children is not ordinarily 
accompanied by tremors. 

The youngest infant in my practice who apparently derived the ague 
from its mother, and probably through the foetal circulation, had the fol- 
lowing history : Its mother had occasional attacks of tertian intermittent 
during the two years preceding her confinement, and her baby when one 



282 INTERMITTENT FEVER. 

week old was observed to have the same disease, occurring also each 
second day, the coldness and blueness in the first stage of the paroxysm 
lasting from half an hour to one hour. 

It is not fully ascertained whether a nursing infant may contract inter- 
mittent fever by lactation, but if it is admitted that it is sometimes com- 
municated to the foetus through the maternal circulation, it does not seem 
improbable that the specific principle occasionally enter the milk as well 
as other secretions. I have frequently remarked the presence of the dis- 
ease in nursing infants whose mothers were affected, and in one instance 
an infant at the breast, whose mother had the ague, having contracted it 
in a suburban village, but was since living in a non-malarious part of the 
city, presented evident symptoms of the disease. Similar observations by 
Frank, Burdel, and others, do not indeed fully prove the communicability 
of intermittent fever by lactation, but render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active, or the condition 
of system is favorable for its reception, the disease may commence soon 
after exposure. Thus, in tropical regions, travellers exposed for a single 
night have been known to sicken within twenty-four hours ; but in our 
cooler latitude, a longer incubative period is the rule. In the infant, how- 
ever, in our climate, intermittent fever often begins in a very short time 
after exposure, though there may be an incubative period of some weeks. 
The following have been my observations relating to this point: A. M., 
female, 8 months old, remained two days on Long Island, in October, 
1870, and three days after her return to the city, a quotidian commenced. 
P. S., male, 11 months old, remained three days on Long Island, and a 
quotidian commenced four days after his return. K., 9 months old, re- 
mained on Staten Island one week, and eleven days after his return, a 
tertian commenced. G. K., aged 3 years, remained a day and a night on 
Staten Island in 1870 ; three weeks afterwards intermittent fever com- 
menced, preceded by a week of languor. A. U., female, aged 2 years and 
2 months, had the first paroxysm of a tertian, two and a half weeks after 
returning from a visit of one week in Hoboken. As there was no malaria 
in the portions of the city where these infants resided, the incubative 
periods are nearly ascertained. 

Whatever may be the nature of the malarial poison, whether a vege- 
table cell, as Prof. Salisbury believes, or something else, it often clings 
tenaciously to the system, and is probably reproduced in it, even under 
circumstances favorable for its elimination. Thus, at one of my cliniques 
at Belle vue Hospital Medical College in 1871, a child, 10 years old, was 
presented, who had had every year for seven years attacks of intermittent 
fever. The disease was contracted at the age of three years in Harlem, 
and the subsequent residence of the family had been in a part of the city 
where there was no malaria. 



SYMPTOMS. 283 

Symptoms In infancy, and especially prior to the age of eighteen 

months, the symptoms differ in certain respects from those which charac- 
terize the malady in the adult, and are universally known. In childhood 
.the symptoms are similar to those in the adult, and need not, therefore, be 
described in this connection. 

In the infant the type as we have seen is quotidian, with now and then 
a tertain. Advancing beyond the age of eighteen months, we meet more 
and more cases of the tertian type, and in childhood it is the common 
form. I have known the quotidian in the infant, when cured, to reappear 
a few weeks after as a tertian; but ordinarily it remains quotidian, unless 
the patient has reached the age at which the tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the adult, 
but while the second, or febrile, is well marked, the first and third are 
much less pronounced. The patient does not shake (exceptionably, one 
does even within the first year) in the first stage, but a slight tremor may 
or may not be observed. The countenance presents a sunken appearance; 
the lips and fingers are livid, Avhile portions of the surface not livid are 
pallid, with the goose-flesh appearance, which is, however, less marked 
than in children of a more advanced age. The blood leaves the sur- 
face, which consequently shrinks, while it accumulates in the veins and 
internal organs ; the pulse is feeble, and readily compressed ; the surface 
grows cool from the diminished supply of blood, but the breath is warm, 
and the internal temperature, so far from being reduced, is elevated two 
or three degrees. The parents may be alarmed at the sudden sinking of 
the vital powers, and seek medical advice, but in other instances the first 
stage is so slight that it passes unperceived till they have been taught to 
watch for it, and the second stage first attracts attention. 

In the second or febrile stage, which immediately succeeds, the pulse 
becomes full and rapid, 120 to 130 or 140 beats per minute, and the ex- 
ternal as well as internal temperature is elevated as in few other diseases 
(104°-108°). The face is flushed, surface dry, and head painful, as 
evinced by the features. This stage lasts about two or three to six or 
eight hours. The third stage, or that of perspiration, succeeds, which 
terminates the suffering of the patient till the following paroxysm. In 
infancy the perspiration is not abundant, and in the first half of this period 
is nearly absent. In the interval of the paroxysms the patient appears 
well, except a degree of languor. 

In twenty-four of the cases of infantile intermittent which I have treated, 
my notes describe the character of the paroxysms. In sixteen of these 
there was no chill or trembling' in the first stage, but blueness and cool- 
ness of the extremities and features, and sudden prostration. This stage 
lasted from ten minutes to one hour. In the eight remaining eases the 
infants were observed to tremble or shake as in adult cases. The perspira- 



284 INTERMITTENT FEVER. 

tion of the third stage was in nearly all cases slight and of short duration, 
and in some was not observed. 

During the cold stage, passive congestion of the internal organs occurs 
to a greater or less extent, but the circulation is equalized during the re-, 
action of the second stage. The spleen, whose capsule is distensible, soon 
enlarges in many patients, in consequence of the frequent and great con- 
gestions, constituting the " ague cake." This enlargement is more com- 
mon in children than adults. Since my attention has been particularly 
directed to this subject, I have been able to feel the enlarged spleen, by 
examination through the abdominal walls, in probably one-third of the 
cases under the age of ten years. This organ returns to the normal size 
after the ague is cured. From the intimate relation of the spleen to the 
composition of the blood, it is evident that the character of this fluid must 
be affected if intermittent fever be protracted. The blood becomes more 
and more impoverished, and a state of decided hydremia supervenes. A 
few weeks' continuance of the ague suffices to produce decided . pallor of 
the features, and surface generally, and as all watery blood is prone to 
transudation, such patients not infrequently present more or less oedema of 
the face, ankles, and other parts. Sometimes, also, especially under un- 
favorable hygienic circumstances, purpuric spots (purpura hemorrhagica) 
appear under the skin, affording additional proof of the change which the 
blood has undergone. 

In long-continued cases of malarial disease in the adult waxy degenera- 
tion of organs is apt to occur, as well as melanaamia. Pigment cells, flakes, 
and particles appear in the blood, the coats of the minute arteries, and in 
various organs, as the spleen, liver, etc. In the child these results are 
more rare. 

Intermittent fever in children, if proper remedial measures are em- 
ployed at an early period, is ordinarily not dangerous, and is quite amen- 
able to treatment ; but that comparatively infrequent and fatal form of it, 
designated the pernicious, occurs more frequently in children than adults. 
In New York city, where the type of malarial diseases is mild, I have 
never met a case of pernicious intermittent in the adult, but I can recall 
to mind such cases in children, two of them fatal. This form of the fever 
occurs in a smaller proportionate number of cases in infancy than in child- 
hood, probably because the cold stage is less pronounced. In the pernicious 
ague the system is overpowered — it does not react in a degree commen- 
surate with the intensity of the disease. The patient enters the cold stage, 
becomes stupid, and,Jf not relieved by prompt and efficient measures, 
passes into fatal coma. A type of the disease, therefore, which would 
not be pernicious in a robust individual, may be such in one of a broken- 
down constitution and feeble reactive power. In most cases occurring in 
children the coma is preceded by eclampsia, which is apt to be general and 
protracted. 



SYMPTOMS. 285 

Eclampsia increases the passive congestion of the cerebro-spinal axis 
already present in this stage, and if not speedily relieved may end in 
transudation of serum over the surface of the brain, and perhaps menin- 
geal apoplexy, causing fatal coma. This has occurred twice in my prac- 
tice. 

Sometimes in young children the diagnosis of intermittent fever is 
doubtful, either because the disease has not continued sufficiently long, 
or there has not been the characteristic paroxysm. The patient may be 
feverish, and fretful, with anorexia, and evidences of headache, but with- 
out the usual distinctive symptoms. I have sometimes in such cases been 
able to establish the diagnosis by detecting enlargement of the spleen. In 
examining for the " ague cake," the child must lie quietly on its back, and 
the fingers, placed midway between the epigastrium and umbilicus, be car- 
ried gently but with firm pressure outward in the direction of the spleen, 
when the anterior edge of this organ will be felt, if it be enlarged. It is 
impossible to make the examination when the child cries, on account of 
the contraction of the abdominal muscles. 

Treatment It is evident that no time should be lost in applying ap- 
propriate remedies in a case of infantile ague ; for, although the first 
paroxysm may be mild, the next may be more severe, and attended by 
danger. Moreover, the sooner the disease is cured the less liable it seems 
to be to return. Therefore we prescribe at once the sulphate of quinia or 
cinchonia, one and a half grains of the latter producing the effect of about 
one grain of the- former. Our experience in the children's class in the 
Outdoor Department has been chiefly with the sulphate of cinchonia, on 
account of its cheapness, and there has yet been no case of ague which it 
has failed to control. A recent writer has published statistics showing his 
success in curing intermittent fever by this agent, but nothing in thera- 
peutics is more easy than to cure this disease in our climate by either of 
the sulphates mentioned. The chief difficulty consists in preventing a re- 
turn. To an infant of two years I prescribe one grain of sulphate of quinia, 
or the equivalent of sulphate of cinchonia, three times daily, till all symp- 
toms of the ague have disappeared ; then twice a day during the subsequent 
week, and afterward once a day for some days ; and finally twice or thrice 
a week. It is only by the protracted use of the drug in occasional doses 
that the return of the intermittent can be prevented. 

It is important in administering these sulphates to infants to employ a 
vehicle which will, so far as possible, disguise the bitterness. The vehicle 
which I prefer for their administration is the elixir adjuvans or elixir 
tarax. co. The following formula is for a child of three years : — 

I£. Qui. sulphat., gr. xij ; 

Elixir adjuvantis 3Jss. Misce. 

One teaspoonful three times daily. The first dose should be adminis- 



286 REMITTENT FEVER. 

tered immediately after the fever abates. In this climate two or three 
days suffice to cure the disease, after which by daily but gradually dimin- 
ished use of the medicine in the manner stated above, the return of the 
malady is prevented. Protracted cases attended by ancemia require the 
use of iron in addition to the remedy which is designed to control the 
disease. 



CHAPTER II 

REMITTENT FEVER. 



If a physician were to consult the standard treatises on diseases of 
children, in order to ascertain the nature of remittent fever, he would 
rise from the perusal with no clear idea of it. One tells us that the re- 
mittent fever of children is identical with typhoid fever of adults ;. another, 
that it is a gastro-intestinal inflammation ; and, finally, Hillier believes 
that there is properly no such disease, and that the term should be dropped 
from the nosology of children. There is, however, a remittent fever of 
children as well as adults, and much of the confusion which exists in refer- 
ence to it arises from the fact that writers have not kept in view what 
constitutes a fever. 

Febrile action which has a local cause is not an essential fever, and 
should not be described as such. It happens that in children a sympto- 
matic remittent fever arises from a variety of local causes, as dentition, 
intestinal worms, subacute gastro-intestinal inflammation, etc. But all 
such cases should be excluded from our consideration of remittent fever, 
as clearly as we distinguish the continued fever of pneumonia or bron- 
chitis from that of typhus or typhoid. 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain propor- 
tion of cases, produce a fever which does not intermit, but continues with 
more or less pronounced exacerbations a certain number of days, when it 
ceases or becomes intermittent. Those who practise in malarious localities 
notice a larger proportion of cases of remittent fever among children 
than adults, because their constitutions are less able to resist the malarial 
poison, so that an exposure which in an adult would produce milder dis- 
ease, namely, a tertain ague, is apt to cause a quotidian or remittent in 
the child. In young and feeble infants the proportionate number who 
have remittent fever is large. Cases, too, are not infrequent in localities 
not malarious, of a remittent fever, occurring more frequently in the 
spring and autumn than in other seasons. Some of these cases are per- 
haps a mild type of typhus, but in most instances the conditions do not 



SYMPTOMS — DIAGNOSIS. 287 

appear to be present which ordinarily give rise to typhus, and they do not 
occur in connection with cases of typhus in adults. The cause, though 
obscure, is apparently atmospheric. 

The symptoms of remittent fever vary in different cases. The exacer- 
bations and remissions are more pronounced in some than others. Even 
in those cases in which the fever is due to paludal emanations, and occurs 
in connection with cases* of the intermittent, the febrile movement may be 
almost uniform, slight exacerbations occurring in the latter part of the 
day. In other cases the exacerbations and remissions are pronounced, the 
febrile excitement abating in a perspiration. Occasionally the fever is 
higher on each second day. Cephalalgia is common, and in severe cases 
delirium and stupor are not infrequent. There may be distinct remissions 
in the beginning, and afterwards, for a few days, the fever be pretty uni- 
form, when it again remits or ceases. The tongue is covered with a light 
fur. Thirst, loss of appetite, a tendency to constipation, scanty and high- 
colored urine, containing perhaps urates, and a cough due to mild bron- 
chitis, are common symptoms. 

"When remittent fever is due to marsh emanations, the same anatomical 
characters are doubtless present as in the adult, namely, blood containing 
more or less pigmentary matter, enlargement of the spleen, bronzing of 
the spleen, and, in severe cases, of the liver, and sometimes of the brain. 

The diagnosis is not always easy. On the one hand, local diseases 
with symptomatic remittent fever are to be excluded, and, on the other, 
typhus and typhoid. The discrimination of it from typhus and typhoid 
fevers is practically of little moment, but it is a matter of vital importance 
to make a differential diagnosis between it and the local diseases. I have 
known one of the acutest diagnosticians and most eminent physicians of 
New York mistake incipient meningitis for it, a mistake indeed not un- 
common. The points involved in a differential diagnosis will be consid- 
ered in our descriptions of the local diseases. 

Treatment If we have ascertained by a careful examination that 

the fever is remittent, and not symptomatic but essential, there is one 
remedy which is required in nearly all cases, namely, quinia, or its equiv- 
alent, cinchonia. Mild febrifuge medicines, with light diet, may be first 
employed in sthenic cases, in which the pulse is full and strong, and the 
quinia given when the fever has somewhat abated. The diet should be 
bland, but nutritious, and the bowels be kept regularly open by citrate of 
magnesia or other mild aperient. Bromide of potassium or hydrate of 
chloral may be occasionally employed as recommended in the treatment 
of typhoid fever, to produce quietude or sleep, in cases attended by de- 
lirium or insomnia A warm mustard foot-bath and cool applications to 
the head are useful in such cases. 



288 TYPHOID FEVER. 



CHAPTER III. 

TYPHOID FEVER. 

Typhus and typhoid fevers occur in children, but the former is mild 
and infrequent, rarely occurring except when adults of the same household 
are affected. It requires little treatment, except good nursing. Typhoid 
fever, on the other hand, is not infrequent in children, and, as it presents 
certain peculiarities prior to the age of puberty, it is proper to describe it 
in this connection. This disease is much less frequent in infancy than in 
childhood, and in the first half of infancy is believed to be rare. Still, 
there can be no doubt that many cases in the first years of life are not 
diagnosticated, being mistaken for subacute and protracted entero-colitis. 
It may, therefore, be more common in the infant than is commonly sup- 
posed. Its period of greatest frequency in children is between the ages 
of six and twelve years. 

Causes. — It is now generally admitted that typhoid fever is mildly 
contagious, and that its specific principle abounds largely in the dejections 
and excretions of the patient. It is uncertain whether it is communicable 
by the breath of the patient, or exhalations from his surface. If it is, it is 
slightly so, while numerous observations demonstrate its communicability 
through the use of night-stools or privies which contain the evacuations. 

There is little doubt also that typhoid fever originates de novo, caused 
by the miasm produced by decaying animal or vegetable matter. Numer- 
ous cases have been observed in which it originated from defective sewer- 
age, or decaying vegetables in cellars, in localities in which no case had 
previously been observed. The germs of the disease may not only be 
received into the system by inspiration, but also through the stomach, for 
the use of well-water which contains the drainage of sewers has repeatedly 
been known to cause it. Boys are more frequently attacked than girls ; 
according to some statistics in the proportion of three to one. Deteriora- 
tion of the health from general causes increases the liability to be attacked. 
On the other hand, those having tuberculosis, carcinoma, heart disease, 
and probably certain other visceral lesions, are more apt to escape than 
those in health. 

Anatomical Characters As typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. 
No alteration, however, has been discovered in this fluid peculiar to typhoid 
fever. The amount of fibrin is diminished as in most of the essential fevers, 



ANATOMICAL CHARACTERS. 289 

and its coagulation is feeble, forming, when the blood stands, soft, small 
and dark clots. When the fever has continued for some time, a state of 
anaemia more or less decided supervenes, in which the amount of albumen 
and blood-corpuscles is diminished. Although there are often decided 
symptoms referable to the nervous system, no constant changes have been 
discovered in the brain or spinal cord. The changes observed in them 
when death has occurred in the course of typhoid fever have been for the 
most part due to other causes. It is different with the respiratory system. 
After the first week of typhoid fever bronchitis is almost as constant as 
inflammation of the fauces in scarlet fever, and accordingly we find in 
fatal cases redness and thickening of the bronchial mucous membrane, 
which is covered with a viscid and ordinarily scanty secretion. Hypo- 
static congestion of the lungs, with more or less oedema, and in severe and 
enfeebled cases hypostatic pneumonia, are not uncommon. In the bron- 
chitis and state of feebleness we have the causes of pulmonary collapse, 
and this lesion is not infrequent over limited portions of the lungs, espe- 
cially if the bronchitis affects the smaller tubes. 

The lesions occurring in the digestive system are important. The mu- 
cous membrane of the small intestine is more or less injected, and at an 
early period, even by the second or third day, the patches of Peyer, soli- 
tary glands, and at the same time the mesenteric, begin to enlarge. It has 
been stated by high authorities that the enlargement is due to infiltration 
with a peculiar substance, which has been termed the typhous material. 
I have made microscopic examination of these glands in typhoid fever of 
the adult, and have found a notable increase of the small round granular 
cells of which these glands are composed. I do not, therefore, doubt that 
the enlargement is due mainly to hyperplasia of the cellular elements of 
the glands, though there is probably infiltration to a certain extent of 
inflammatory products between the cells. The mucous membrane over the 
glands undergoes inflammatory thickening and softening. In the adult, 
sloughing of this membrane is frequent, with the disintegration of the 
glands and their elimination into the intestines, producing ulcers, small 
and circular, corresponding with the site of the solitary glands, laro-e and 
oval or irregular, corresponding with the site of the agminate. Disinte- 
gration of these glands and the formation of ulcers are less frequent in 
children than in adults. In the adult, who recovers, the mesenteric glands, 
and those of the solitary and agminate which are not destroyed, return to 
their normal state by fatty degeneration, liquefaction and absorption of the 
redundant cells. In the child this is the common result, instead of slouch- 
ing and disintegration, as regards both the solitary and agminate glands, 
and uniform result as regards the mesenteric, and I may add bronchial 
glands, which are also in a state of hyperplasia. The absence of ulcer- 
ation or its slight extent affords explanation of the fact that intestinal per- 
foration is very rare in children. 
19 



290 TYPHOID FEVER. 

The spleen gradually enlarges, often to twice the normal size, has a dark- 
red color, and is softened. Enlargement of the spleen possesses great diag- 
nostic value in those cases in which the diagnosis is obscure. For w T hile 
very similar intestinal lesions may occur in chronic entero-colitis, the co- 
existence of these lesions with the splenic enlargement and softening shows 
the constitutional nature of the affection. 

In cases which are severe, and which present a decidedly adynamic 
type, the muscles become soft and flabby, the action of the heart is feeble, 
and more or less passive congestion of the viscera results. In such cases 
congestion of the kidneys and albuminuria are not infrequent. 

Symptoms — Typhoid fever has a prodromic stage of a few days, some- 
times of a week or more, in which the child appears languid, indisposed to 
play, and has little appetite, but complains of no pain unless occasional 
slight headache, and has no symptom which would lead the friends or even 
physicians to suspect the grave nature of the disease which impended. By 
and by a slight fever occurs. 

The febrile movement, which gradually becomes more pronounced, re- 
mits, but does not cease in the morning, and has evening exacerbations. 
After the first week of fever the remissions are less marked, but the fever 
is not uniform at any period in its course. Hence some of our ablest writers 
on diseases of children continue to designate typhoid fever of children re- 
mittent fever, fully aware of its identity with typhoid fever of the adult. 
As the case advances, the appetite fails, all solid food being refused, and 
liquid food being taken more from thirst than hunger. The tongue in the 
first week, and in some patients throughout the course of the disease, is 
covered with a light moist fur, while in others having a graver type of the 
fever the tongue after the first week is dry and brown. During the prodromic 
period, and in the first w T eek, the bowels act regularly, or are slightly re- 
laxed, and they are readily affected by purgative medicines. After the 
first week there is in most children a tendency to diarrhoea, which requires 
now and then the use of astringents, the stools being watery and brown, or 
dark yellow. The abdominal walls are seldom retracted, but prominent, 
especially after the first week, in consequence of meteorism which is present 
in children as well as adults. Sometimes there is apparent tenderness, when 
pressure is made over the right iliac region, but this must not be confounded 
with hyperesthesia, which is common in the commencement of febrile dis- 
eases in children, and which is observed especially upon the abdomen, chest, 
and inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bronchitis is 
developed, the respiration is ordinarily more accelerated, though not in a 
marked degree, unless in those exceptional instances in which there is an 
abundant collection of mucus in the smaller bronchial'tubes. A cough is 
often present, dependent on the bronchitis, and varying in character ac- 



SYMPTOMS. 291 

cording to the degree and stage of the inflammation. In the first days of 
the fever it is infrequent, and hacking ; at a later stage it is more frequent, 
and not so dry, though in cases of ordinary severity the amount of expec- 
toration is inconsiderable. Hypostatic congestion, oedema, hypostatic pneu- 
monia, splenization, or thickening of the alveolar walls, and collapse, which 
may and some of which not infrequently do occur in the advanced disease, 
increase more or less the frequency of the respiration and the cough, and 
modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. 
It gradually becomes more accelerated, numbering in the second week 123 
or more ; in grave cases even 160. The more frequent the pulse, the greater 
the danger and more unfavorable the prognosis. During the exacerbations 
the number of pulsations per minute is 15 or 20 more than in the remis- 
sions. The change in temperature corresponds with that of the pulse, being 
from 1° to 2° higher in the exacerbation than remission. The extremes 
of temperature in cases of ordinary severity are about 101° and 104°. A 
temperature above 105° shows' a grave, probably, a malignant, type of 
the disease, or else a serious complication. 

There is great variation as regards the symptoms referable to the nervous 
system. Headache is common in the prodromic and initial stages, after 
which it ceases. A few are delirious even from an early period, screaming 
loudly, or muttering incoherently, but the majority are quiet, having, in- 
deed, a degree of mental dulness, but being able to appreciate questions 
when aroused, and answering correctly. Subsultus tendinum and carpho- 
logia, which some exhibit, show that there is profound disturbance of the 
nervous system. Epistaxis occurs occasionally in the first week as in the 
adult, but is not abundant. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former 
than latter ; sometimes the number of spots is less than half a dozen. 
Sudamina are common in the second and third weeks, and perspirations 
may occur at any time in the course of the fever, but without ameliora- 
tion of symptoms. More or less deafness is common, being in most in- 
stances a purely nervous symptom, without, therefore, any structural 
change in the ear, but it is possible, as has been suggested by certain 
waiters, that it sometimes results from inflammatory thickening of the 
Eustachian tube or external meatus, or to a weakened and flabby state 
of the muscles of the ear. 

The duration of typhoid fever is not uniform ; while mild cases may end 
in two weeks, those of a severer type continue three or even four. The 
patient becomes progressively more emaciated and feeble. In protracted 
and severe cases his condition seems very unpromising to one not familiar 
with the clinical history of the fever. Pale, emaciated, and feeble, prob- 
ably passing his evacuations in bed, taking little notice of objects around 



OQQ 



TYPHOID FEVER 



him, lie presents, at the close of the third week, an appearance of helpless- 
ness, notwithstanding the best of nursing, and the constant employment of 
sustaining measures, which is truly discouraging. 

Complications — The chief complications of typhoid fever are broncho- 
pneumonia, already sufficiently described, enteritis, intestinal hemorrhage, 
peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient 
about ten years old, in whom the fever had nearly terminated, by the 
sudden accession of croup. There is, as we have seen, in ordinary cases, 
more or less inflammation of the mucous membrane of the air-passages, 
and of the intestines especially in the vicinity of the patches of Peyer. It 
is easy to understand how, under circumstances which may arise in the 
fever favorable to the development of mucous inflammations, the bronchitis 
and enteritis may so increase as to constitute complications. They are the 
most frequent of the serious complications. 

Intestinal hemorrhage is an occasional accident. Hillier met four cases 
in thirty of the fever. It indicates the presence of ulcers upon the sur- 
face of the intestines. The younger the child, the less the liability to it. 
Some, in whom it has occurred, recover, but others die. Otitis, com- 
mencing with pain, and producing a discharge which may continue for 
weeks, is not rare, though less frequent than in scarlet fever. The otitis 
is commonly external, but it may, in scrofulous subjects, extend to the 
middle ear. 

Intestinal perforation is more rare in children than in adults, as might 
be inferred from the statement already made, that intestinal ulceration is 
less frequent and extensive in them. Statistics show that perforation oc- 
curs only once in 232 cases. Therefore, as perforation is the common 
cause of peritonitis in this disease, this inflammation is a rare complication. 
Peritonitis may, however, occur in typhoid fever without perforation. In 
one such case (an adult) in the fever wards attached to Charity Hospital 
local peritonitis with fibrinous exudation occurred opposite two ulcerated 
paches of Peyer, the ulcers extending nearly to the peritoneum, but not 
perforating. The lesions observed in this case throw light on those cases 
of peritonitis complicating typhoid fever which recover, the cause of which 
has received a different explanation. 

In advanced and greatly debilitated cases, thrush sometimes appears in 
the interior of the mouth, and upon the fauces. It is always an unfavor- 
able prognostic symptom in children suffering from chronic or protracted 
disease. Parotiditis is also a rare complication. 

Diagnosis. — This is more difficult in children than in adults, and the 
j^ounger the child the greater the difficulty. In infants protracted entero- 
colitis, with febrile action and dry furred tongue, cannot in certain cases 
be positively diagnosticated from typhoid fever by the symptoms and 
clinical history. Typhoid fever is believed, however, to be rare at this 
age. When, however, as now and then happens, a young child presents 



DIAGNOSIS — PROGNOSIS. 293 

the symptoms characteristic of protracted subacute entero-colitis, or ty- 
phoid fever, and older members of the household have the fever, it is 
highly probable that the case is one of the latter disease, and it should be 
treated accordingly. 

Even in older children typhoid fever is apt to be mistaken for simple 
subacute enteritis, or entero-colitis, or vice versa. The following facts aid 
in the differential diagnosis. In typhoid fever there is total loss of ap- 
petite, while in the subacute intestinal inflammation food is not entirely 
refused. Diarrhoea commences early in the inflammation, while in the 
fever it is not ordinarily till after the lapse of a few days. Abdominal 
tenderness in the fever is not appreciable, or is located in the right iliac 
region ; in the other disease it is general over the abdomen, or located in 
the umbilical region. In typhoid fever there is bronchitis with a cough 
which is absent in the inflammation. In typhoid fever there are certain 
other symptoms, more or fewer of which are present in most cases, and 
which do not occur in the intestinal diseases, except as a coincidence ; 
for example, headache, epistaxis, stupor, delirium, and perhaps the rose- 
colored spots. 

Typhoid fever may be mistaken for meningitis, during the first week, 
but in meningitis there is more constipation, irritability of stomach, and 
less elevation of temperature. Moreover, in meningitis, at a comparatively 
early stage, we are able to detect patches of congestion of the features 
coming and disappearing suddenly ; and slight inequality of the pupils, or 
their oscillation when the light is uniform ; signs which are lacking in 
typhoid fever. In a doubtful case the ophthalmoscope might be em- 
ployed, which in meningitis discloses congestion of the vessels of the 
retina, oedema, etc., anatomical changes which do not pertain to typhoid 
fever. 

The differential diagnosis of typhoid fever and acute tuberculosis may 
be made by attention to the following points. In tuberculosis there is 
cough, with some acceleration of respiration from the first, without epis- 
taxis, stupor,' or other nervous symptoms, and without the abdominal 
symptoms which are so prominent in the fever. 

Duration The duration of typhoid fever varies from two to about 

four weeks, but complications which may arise may protract the febrile 
movement. Recovery from a severe and protracted attack is slow, several 
weeks or even months elapsing before complete restoration to health. A 
tendency to diarrhoea often continues several weeks after the fever proper 
ceases, necessitating a rigid oversight of the diet, and the occasional em- 
ployment of astringents. 

Prognosis — A much larger percentage of children recover than of 
adults. Although there is great emaciation with loss of strength, recovery 
may be confidently predicted, provided that no serious complication oc- 
curs. In fatal cases which I have met, the unfavorable result occurred 



294 TYPHOID FEVER. 

as a rule From the complications, rather than directly from the malady. 
The condition in which severe typhoid fever leaves a patient is favorable 
to the development of tubercles, and now and then they occur, disappoint- 
ing our expectations and prediction of recovery. 

Treatment As typhoid fever is self-limited, the treatment required 

in ordinary cases is simple. It should be of a sustaining nature, both as 
regards diet and medicinal agents, and any untoward symptoms should be 
promptly met by appropriate measures. The food should be in liquid 
form ; solid food is, indeed, in most cases, refused. Beef-tea, milk, rice or 
barley-water with milk, may be allowed from the first. Mild cases require 
no stimulants, still the moderate use of wine is not contraindicated in such 
cases, and may be allowed at an early period. In grave cases, character- 
ized by a dry and furred tongue, and quick and compressible pulse, milk- 
punch or wine-whey should be employed in suitable quantity at regular 
intervals. 

When the fever is mild and pursuing its normal course, one of the 
mineral acids, as the dilute muriatic, or even a simple febrifuge may be 
employed, as spts. astheris nitrosi, with syrup of ipecacuanha. 

]J. Spts. aether, nit., 5ij 5 
Syr. ipecac, 5iij ; 
Syr. simplic, §jss. Misce. 
Dose, one teaspoonful every three hours to a child of six years. 

If the febrile movement is considerable, or if it has distinct evening 
exacerbations, quinine is indicated, and in asthenic cases it may be em- 
ployed in smaller doses as a tonic. In such conditions it will be found 
useful. In cases attended with great restlessness or delirium, an appropri- 
ate dose of bromide of potassium or hydrate of chloral at night will pro- 
cure rest, and be followed by no unfavorable result. I prefer the hydrate 
of chloral given in a small dose. A single dose of two or three grains of 
this agent will generally be sufficient. For the diarrhoea, I ordinarily 
prescribe paregoric, or some other opiate, with subnitrate of bismuth, in 
chalk mixture. The state of anamiia which is present in the advanced 
disease and in convalescence requires the employment of iron. The citrate 
of iron and quinine will, under such circumstances, be found useful. 



CEREBROSPINAL FEVER, 295 



CHAPTER IV. 

CEREBRO-SPINAL FEVER. 

Cerebrospinal fever, designated also spotted fever, tetanoid fever, 
and cerebro-spinal meningitis, is an epidemic constitutional disease, mani- 
festing itself by lesions and symptoms which pertain chiefly to the nervous 
system. Descriptions of occasional epidemics, which appear to have been 
of this malady, have been left us by writers as far back as the fifteenth 
century, but it was not clearly distinguished from typhus on the one hand, 
and local inflammatory affections of the cerebro-spinal axis on the other, 
till after the present century commenced. 

Few diseases more urgently demand elucidation than this, for while it 
is very fatal, there is discrepancy in the views of physicians in regard to 
its cause, nature, and proper treatment. As cerebro-spinal fever results 
from some pervading cause, probably as we will see atmospheric, we would 
expect to observe effects of this cause, in some other way, in addition to 
the disease of which we are treating. Accordingly, the histories of at 
least a portion of the epidemics of cerebro-spinal fever show an unusual 
prevalence of pneumonias of an ataxic type, and sometimes also of pha- 
ryngitis, in addition to the cerebro-spinal disease, and this disease is 
sometimes complicated by congestion, and less frequently by inflammation 
of the lungs. The prevalence of typhoid pneumonias during cerebro- 
spinal fever was long ago observed. Thus, in Bascome's history of epi- 
demics, it is stated that " epidemic encephalitis and malignant pneumonias 
prevailed in Germany (Webber) in the sixteenth century." In this 
country, in the epidemics of cerebro-spinal fever from 1811 to 1815, 
pharyngeal and pneumonic inflammations were unusually frequent. In 
more recent epidemics observers have not so often, but have occasionally, 
recorded the prevalence of pneumonias in connection with cases of the 
cerebro-spinal disease. Accordingly, Webber, who has examined the 
histories of the various epidemics, describes in his prize essay a second 
variety of cerebro-spinal fever, which he designates pneumonic, in which 
the cerebro-spinal axis is involved but slightly, or not at all, and the 
brunt of the disease falls upon the respiratory organs. In certain epi- 
demics, according to him, the pneumonic form is common, while in others 
it is infrequent. 

During the time when the recent epidemic in New York city was at 
its maximum, an unusually large number of cases of pleuro-pneumonia of 
an asthenic type, and I may add, I think, of pharyngitis, occurred ; and 



296 CEREBROSPINAL FEVER. 

while cerebro-spinal fever rarely affected those above the age of fifty 
years, many of those with pneumonia were old people. According to the 
statistics of the New York Health Board, there were 1707 deaths from 
diseases of the respiratory organs, exclusive of phthisis, during the four 
months from February 1st to June 1st, 1872, when the epidemic of 
cerebro-spinal fever was at its height, while during the remaining eight 
months of the year there were only 1336 deaths from the same diseases; 
and I need not add that deaths from aifections of the respiratory apparatus 
are largely from pneumonia. Moreover, I am of opinion, from my own 
observations, that many of the cases of pneumonia, during that period, 
presented symptoms of greater gravity than usually accompany this form 
of inflammation of the same extent. The patients were greatly prostrated 
from the first, and in some of them febrile movement, muscular pains, 
restlessness, or delirium preceded for hours or even days the pneumonic 
symptoms, affording evidence that the lung disease, if not due entirely to 
the same atmospheric conditions which give rise to cerebro-spinal fever, 
was at least under their influence. Although it is probable that pneu- 
monia occurring during an epidemic of cerebro-spinal fever is in most 
instances a strictly local malady, as it is at ordinary times more or less 
modified perhaps by the epidemic influence, there can be little doubt that 
Webber's view is correct, that there are occasional cases of true cerebro- 
spinal fever, in which the local manifestations are chiefly in the lungs ; 
cases in which, the cerebro-spinal affection is of less importance apparently 
than the pulmonic. I might relate striking examples, observed in the 
New York epidemic of 1872. 

In one case three prominent physicians, one of them known throughout 
the country as an excellent diagnostician, pronounced the disease cerebro- 
spinal meningitis, but on the sixth day, the cerebro-spinal symptoms 
having considerably abated, pneumonia occurred, and afterwards the pul- 
monary symptoms predominated. 

Cause Does the cause of cerebro-spinal fever emanate from the soil? 

Facts show that it does not. Most of the epidemics commence in winter 
when the ground is frozen ; the disease occurs in valleys, and on hilltops, 
and upon all varieties of soil ; it invades one district, passes over another 
adjoining, and affects, perhaps, a third beyond, although the geological 
formation of all is the same. 

Does the cause exist in the diet, as some competent observers have sup- 
posed ? The following facts, I believe, are sufficient to justify a negative 
answer : Of two adjacent localities, in which the nature of the diet of the 
inhabitants is the same, one escapes and the other is visited by the epi- 
demic ; an epidemic sometimes prevails here and there over an area of 
many thousand miles, as recently in North America. It is hardly reason- 
able to suppose that any deleterious property would occur in the food over 
so wide a territory. An epidemic ceases, although the food of the people 



cause. 297 

continues the same. Infants at the breast, having only the mother's milk, 
are sometimes affected, and likewise certain animals, whose food is very 
different from that of man, and finally the most careful examinations have 
hitherto failed to discover any change in the cereals, or other food, or 
noxious principle sufficient to explain the occurrence of the disease over a 
wide extent of territory. 

There can, therefore, be little doubt that the cause exists in the atmos- 
phere, though so subtle that we may never be able to detect it. Cerebro- 
spinal fever is, indeed, one of many examples in corroboration of the state- 
ment made by Humboldt, that there is no subject of scientific inquiry 
more obscure than the laws which control epidemics. Among the meteor- 
ological conditions which favor the occurrence of this disease, cool weather 
has already been alluded to. Statistics collected in France and the United 
States show that, while 166 epidemics occurred in the six months com- 
mencing with December, only 50 occurred in the remaining six months of 
the year. According to Professor Hirsch, whose statistics were obtained 
largely from central Europe, there were 57 epidemics in winter or winter 
and spring, 11 in spring, 5 between spring and autumn, 4 commencing in 
autumn and extending into winter or winter and spring, and 6 lasting 
through the entire year. 

All observers have remarked the fact that anti-hygienic conditions, 
though obviously subordinate to the unknown atmospheric cause, never- 
theless strongly predispose to this disease. Hence, soldiers in barracks 
and the poor in tenement houses suffer most severely. During the epidemic 
of 1872, in New York, unusually severe or multiple cases occurred for the 
most part where there were obvious anti-hygienic conditions, as in apart- 
ments which were unusually crowded and filthy, or in tenements around 
which refuse had collected or which had defective drainage. The inte- 
resting chart, prepared untler the direction of Dr. Moreau Morris for the 
Health Board, shows that comparatively few cases occurred in those por- 
tions of the city where the sanitary conditions were good. I cannot, how- 
ever, agree with Professor Hirsch that the greater crowding, domiciliary 
and personal uncleanlinesss, and imperfect ventilation in the cool than in 
the warm months, explain the fact that epidemics occur chiefly in winter 
and early spring ; for in clean and well-ventilated apartments, in sparsely 
settled and salubrious localities, epidemics occur for the most part in these 
seasons. Anti-hygienic conditions probably predispose to this disease in 
the same way, and no more than to any other grave epidemic which hap- 
pens to be prevailing, as, for example, to Asiatic cholera, whose ravages 
are largely in the crowded and uncleanly quarters of the poor. 

Is cerebrospinal fever propagated by contagion ? — It is the almost 
unanimous opinion of those who are most competent to judge from their 
observations, that it is either not contagious or is so only in a very slight 
degree. It is certain that the vast majority of cases occur without the 



298 CEREBRO-SPINAL FEVER. 

possibility of personal communication. Thus, in the commencement of an 
epidemic, the first patients are affected here and there at a distance from 
each other, often miles apart, and throughout an epidemic usually only 
one is seized in a family. Children maybe around the bedside of the 
patient, passing in and out of the room without restriction, and yet we 
can confidently predict that none of them will contract the disease if there 
are proper ventilation and cleanliness. And when two or more cases oc- 
cur in a family, it commences at such irregular intervals in the different 
patients that the presumption is strong that they receive it from the same 
extraneous source, and not one from the other, for contagious diseases 
usually have a pretty uniform incubative period. Thus, in the Brown 
family, treated by the late Dr. Sewall (J5T. Y. Bled. Bee, July, 1872), the 
first child sickened January 30th, and the remaining five children at inter- 
vals respectively of 5, 7, 11, 25, and 45 days. The following have been 
my observations relating to this point : — 

Single cases, No. 39 (4 adults). 

Two in a family, No. 16 (8 families). 

Three in a family, No. 3 (1 family). 

In most of the 39 families in which single cases occurred, there were 
children who were allowed free intercourse with the patients. Is there 
any other malady of childhood known to be infectious, which affords such 
a record of non-contagion ? In those instances in which two in a family 
took the fever, those who were last attacked did not seem to receive it 
from those who were first affected, for the reason already stated, namely, 
the very variable intervals between the two cases in the different families. 
The facts, in the family in which three cases occurred, did seem to lend 
support to the doctrine of contagion. A boy, twelve years of age, died of 
cerebro-spinal fever, and was buried on Saturday or Sunday. On the 
following Monday the mother washed the linen of the boy, which had 
accumulated, and within two days was herself affected with the disease. 
She and her infant, who was also seized with it, died. Were such cases 
frequent or not infrequent, the argument in favor of contagion would cer- 
tainly be strong ; but as they are infrequent, it is proper to accept any 
other reasonable explanation instead. The state of the bedding and 
apartments, as observed by me, was such as to render the atmosphere in 
which this family lived noxious in a high degree, and therefore such as to 
attract the prevailing epidemic. Moreover, the mother, exhausted by her 
long watching, and deprived of needed sleep (for the boy was several days 
sick), instead of obtaining the required rest, rendered her system more 
liable to the fever by her self-imposed duties on the day following the 
burial. These manifest anti-hygienic conditions appeared quite sufficient, 
without the aid of any contagious principle, to explain the occurrence 
of the cases in this severely visited family. My statistics, therefore, har- 
monize with the doctrine of non-contagiousness, but it is obviously very 



cause. 299 

difficult to determine from clinical experience whether an epidemic con- 
stitutional disease is absolutely non-contagious, or contagious in a very 
low degree. Experience shows that the attendants upon a case of cerebro- 
spinal fever have immunity, unless the hygienic conditions are very bad. 

Allusion has been made to the fact that this malady sometimes occurs 
among the lower animals. In the epidemic of 1811, in Vermont, Dr. 
Gallop remarks that even the foxes seemed to be affected, so that they 
were killed in numbers near the dwellings of the inhabitants. The recent 
epidemic of New York, it is well known, prevailed among horses several 
months before it occurred among the people. It was common and fatal 
in the large stables of the city car and stage lines in 1871, while among 
the people the epidemic did not properly commence, although there were 
previously isolated cases, till January, 1872. It has been asked whether 
in epidemics like this> in which the lower animals are first affected, the 
disease may not be communicated from them to man ? This obviously 
brings up the question of contagiousness. From my own observations I 
should certainly answer in the negative, for I have not been able to ascer- 
tain that those who had charge of the affected horses in the recent epi- 
demic, as the veterinary surgeons or stablemen, were any more liable to 
the fever than others who were not so exposed. They apparently were 
not, and we must, therefore, believe that this disease is not propagated 
from one species of animals to another, certainly no more than from one 
animal to another in the same species, and the fact that different animals 
are affected by the epidemic is due to the potent and pervading nature 
of the cause. Cerebro-spinal fever is indeed, so to speak, pandemic in a 
double sense ; on the one hand affecting both sexes, different ages, and all 
conditions of people over a wide extent of territory, and on the other 
hand different species of animals, but with little or no contagiousness. 

Not infrequently we are able to discover some exciting cause of the 
fever, usually an exhausting or perturbating influence of some sort. An 
individual whose system is affected by the epidemic influence, and is there- 
fore predisposed to the disease, may, perhaps, escape by a quiet and regu- 
lar mode of life ; but if there is an exciting cause of the nature alluded 
to, the fever may be developed. Among these exciting causes may be 
mentioned overwork, fatigue, mental excitement, prolonged abstinence 
from food, followed by over-eating, and the use of indigestible and im- 
proper food. Thus in one instance in my practice, a delicate young 
woman at the head of one of the departments in a well-known Broadway 
store, was anxious and excited and her energies overtaxed at the annual 
reopening. Within a day or two subsequently the disease commenced. 
Another patient, a boy, was seized after a day of unusual excitement and 
exposure, having in the mean time bathed in the Hudson when the weather 
was quite cool. During the recent epidemic in New York those children 
seemed to me especially liable to be attacked who were subjected to the 



300 CEREBRO-SPINAL FEVER. 

severe discipline of the public schools, returning home fatigued and hungry, 
and eating heartily at a late hour. In one instance which I observed, a 
school girl of ten years returned from school excited and crying, because 
she had failed in her examination and was not ( promoted. In the evening, 
after she had closely studied her lessons, the fever commenced with violent 
headache. Dr. Frothingham (Am. Med. Times, April 30, 1864) writes as 
follows of the brigade in which cerebro-spinal fever occurred in the Army 
of the Potomac : " Under Gen. Butterfield, a stern disciplinarian . . . . 
the men were drilled to the full extent of their powers — often to exhaus- 
tion. I did not at the time recognize this as the cause of the disease in 
question, but I learned that in the present epidemic in Pennsylvania the 
attack generally follows unusual exertion and exposure to cold." Observ- 
ers have long recognized the fact of such exciting causes. Dr. Gallop, in 
his history of the epidemic of Vermont, in 1811, directs attention to the 
severity of the disease among the troops under General Dearborn, who 
were fatigued by marches, and greatly dispirited by a repulse which they 
had sustained from the British. 

Sex It is stated by writers that more males are affected than females. 

Hospital and military statistics show this ; but in family practice, in which 
a large proportion of the patients are children, the number of males and 
females is about equal. Thus in 75 cases occurring in the 20th and 22d 
wards, mainly in the practice of two other physicians and myself, I find 
that there were 39 males and 36 females. Sixty-four of these were chil- 
dren. From January 1st to November 1st, 1872, 905 cases in which the 
sex was stated were reported to the Health Board. Of these 484 were 
males, and 421 females. Dr. Sanderson's statistics of the epidemic in* the 
provinces around the Vistula, the cases being chiefly children, give also 
but a slight excess of males. Probably, therefore, the sex under the age 
of puberty makes no difference in the liability to this disease, and the 
same may be said of all other constitutional affections. Men are more 
liable than women, only when they lead a more irregular life, and are 
subject to more privations and exposures. 

Age Children, as already stated, are much more liable to cerebro- 
spinal fever than adults. The following are the statistics of the Health 
Board relating to this point, the cases occurring in 1872 : — 

Under 1 year, . . 125 

From 1 to 5 years, . . . . . . . . 3.36 

" 5 " 10 '..■" . . • ' . . . . . .204 

" 10 " 15 " 106 

" 15 " '20 " . 54 

" 20 " 30 " . . . . ... .79 

Over 30 years, . . . . . . . .71 

Total, 975 



SYMPTOMS. 301 

In the statistics which I have obtained of 81 cases occurring in the 20th 
and 2 2d wards, the ages were as follows : — 

Under 1 year, ......... 8 

From 1 to 3 years, . . . . . . . .18 

" 3 " 5 " . . . . . . . .20 

" 5 -'" 10 " . . 17 

" 10 " 15 " . 7 

Over 14 years, ......... 11 

Total, 81 

It is seen that nearly three-fourths of the whole number of cases in the 
recent epidemic in New York city were under the age of ten years. The 
statistics of other epidemics occurring in civil practice are similar. Thus 
Dr. Sanderson, in examining the mortuary statistics of the epidemic in 
Germany, ascertained that there had been 218 deaths under the age of 
fourteen years, and only 17 above that age, and although this does not 
show the exact ratio of children to adults, in the entire number of cases it 
is apparent that children greatly preponderated. 

The more advanced the age after childhood, the less the liability to this 
malady ; so that after the middle period of life few cases occur, and after 
the age of fifty years there is nearly an immunity. The oldest two in 
the recent epidemic, of whose cases I have the records, had attained the 
ages respectively of 47 and 63 years. 

Symptoms During epidemics of cerebro-spinal fever, we are now and 

then called to patients who present certain of the characteristic symptoms, 
but in so transient and mild a form that they are soon restored to health. 
The fever is said to have aborted. I have met the following cases : — 

A boy of eight years, previously well, was taken with headache, vomit- 
ing, and moderate febrile movement on April 2, 1872. The evacuations 
were regular, and no local cause of the attack could be discovered. On 
the following day the symptoms continued, except the vomiting, but he 
seemed somewhat better. On April 4th the febrile movement was more 
pronounced, and in the afternoon he was drowsy and had a slight convul- 
sion. The forward movement of his head was apparently somewhat 
restrained. On the 6th the symptoms had begun to abate, and in about 
one week from the commencement of the attack his health was fully 
restored. 

A boy aged six years was well till the second week in May, 1872, when 
he became feverish, and complained of headache. At my first visit, May 
14th, he still had headache, with a pulse of 112. The pupils were sensi- 
tive to light, but the right pupil was larger than the left. The bromide 
and iodide of potassium were prescribed with moderate counter-irritation 
behind the ears. The headache and febrile movement in a few days abated, 
the equality of the pupils was restored, and within a little more than a 
week from the first symptoms he fully recovered. 

Obviously the diagnosis, Avhen symptoms are so mild, must sometimes 
be doubtful ; but as observers in different epidemics report such cases, it 



302 CEREBRO-SPINAL FEVER. 

seems proper to regard them with perhaps occasional exceptions as genuine, 
but aborted cases. The epidemic influence acts so feebly on these patients, 
or their ability to resist it is so great, that they escape with a short and 
trivial ailment. 

Occasionally, also, during the progress of an epidemic, we- meet patients 
who present more or fewer of the characteristic symptoms, but in so mild a 
form that they are never seriously sick, and never entirely lose the appe- 
tite, but the disease, instead of aborting, continues about the usual time. 

Thus, on the 4th of January, 1873, I was called to a girl of thirteen 
years, who had been seized with vomiting followed by headache in the last 
week in December. During a period of six to eight weeks, or till nearly 
the 1st of March, she presented the following symptoms : Daily paroxys- 
mal headache, often more severe in the forenoon ; neuralgic pain in the 
left hypochondrium, and sometimes in the epigastric region ; pulse and 
temperature sometimes nearly normal, and at other times accelerated and 
elevated, both with daily variations ; inequality of the pupils, the right 
being larger than the left during a portion of the sickness. This patient 
was never so ill as to keep the bed, usually sitting quietly during the day 
in a chair, or reclining on a lounge, and she never fully lost her appetite. 
Quinia had no appreciable effect on the paroxysms of pain or fever. 

There can, in my opinion, be little doubt that this girl was affected by 
the epidemic, but so mildly that there was, for a considerable time, much 
uncertainty in the diagnosis. Cases like this, in which the disease is so 
feebly developed, and those in which it aborts, though they deserve recog- 
nition, evidently should not be employed in the statistics. 

Mode of Commencement In all the cases which I have observed, 

cerebro-spinal fever commenced between 12 M. and 6 A.M., and in the 
records of cases published by others the time of commencement, so far as 
I have observed, was between the same hours. The fact that this disease 
does not commence after the repose of night till several hours of the clay 
have passed, shows the propriety, as we shall see hereafter, of enjoining a 
quiet and regular mode of life, free from excitement, and with sufficient 
hours of sleep during the time that the epidemic is prevailing. 

Cerebro-spinal fever usually has no premonitory stage, or it is so slight 
as to escape notice. Exceptionally there are certain premonitions for a 
few hours or days, such as languor, chilliness, etc. Premonitions occur 
more frequently in mild than in severe forms of the fever. The ordinary 
mode of commencement in a typical or somewhat severe case is as follows : 
The patient has a rigor or chill, or rarely two or three of them at irregular 
intervals of some hours. One patient, an adult female, had three or four 
pretty severe chills, the last occurring, from recollection, as late as the 
fourth day. Children often have clonic convulsions in place of the chill, or 
immediately after it, partial or general, slight or severe. Apathy, more or 
less profound stupor, or less frequently delirium succeeds. In the gravest 
cases semi-coma occurs, from which the patient is with difficulty aroused, 



SYMPTOMS. 303 

or profound coma, which, in spite of prompt and appropriate treatment, 
may prove speedily fatal. If aroused to consciousness, he now complains 
of violent headache, with or without, or alternating with equally severe 
neuralgic pains in the neck, some part of the trunk, or in one of the ex- 
tremities. The pupils are dilated, or less frequently contracted, and they 
respond feebly, or not at all, to light. Often they oscillate, and occasion- 
ally one is larger than the other. 

Vomiting, with little apparent nausea, is also an early and prominent 
symptom, evidently having a cerebral origin. It occurred as an initial 
symptom in 51 of oQ cases observed by Dr. Sanderson. Of 61 cases 
observed by Dr. Sewall and myself, neither its presence nor absence was 
recorded in 13 cases, its absence in only 1, and its presence as an early 
symptom in 48 cases. 

Unlike typhus and typhoid fevers, the temperature on the first day is 
usually as elevated as, and sometimes more so than subsequently. Indeed, 
the highest temperature which I have observed in any case was only two 
or three hours after the commencement of the attack in a child of three 
years, namely, an axillary temperature of 107|°. 

Exceptionally the initial symptoms occur in a more gradual manner, 
becoming by degrees more severe, so that a few days elapse before they 
are so pronounced that a clear diagnosis is possible. The febrile move- 
ment, headache, neuralgic pains, lassitude, vomiting, and fretfulness, though 
pretty uniformly present in the commencement, are not in these cases so 
severe at this period as to excite any apprehension. 

Symptoms pertaixixo to the Nervous System Pain, already 

described as an initial symptom, continues during the acute period of the 
malady. It is ordinarily severe, eliciting moans from the sufferer, but its 
intensity varies in different patients. Its most frequent seat is the head, 
where it may be frontal or occipital. It is described as sharp, lancinating, 
or boring. It is also common in the neck, especially the nucha, the epi- 
gastrium, umbilical and lumbar regions, in one or more of the limbs, and 
along the spine (rachialgia). It shifts from place to place, but it is com- 
monly more persistent in the head and along the spine than elsewhere. 
The patient, if old enough to speak, and not delirious or too stupid, often 
exclaims, "Oh, my head!" from the intensity of his suffering, but after 
some moments complains equally of pain in some other part, while perhaps 
the headache has ceased, or is milder. In a few instances the headache 
is absent, or is slight and transient, while the pain is intense elsewhere. 
After some days the pain begins to abate, and by the close of the second 
week is much less pronounced than previously. Vertigo occurs with the 
headache, so that the patient reels in attempting to stand or walk. Con- 
tributing to the unsteadiness of the muscular movements is a notable loss 
of strength, which occurs early and increases. 

The state of the patient's mind is interesting. It is well expressed in 



304 CEREBRO-SPINAL FEVER. 

ordinary cases by the term apathy or indifference, and between this and 
coma on the one hand, and acute delirium on the other, there is every 
grade of mental disturbance. Sometimes patients seem totally uncon- 
scious of the words or presence of those around them, when it appears sub- 
sequently that they understood what was said or done. Delirium is not 
infrequent, especially in the older children and adults. Its form is various, 
most frequently quiet or passive, but occasionally maniacal, so that forcible 
restraint is required. It sometimes resembles intoxication, or hysteria, or 
it may appear as a simpie delusion in regard to certain subjects. Thus 
one of my patients, a boy of five years, appeared for the most part ra- 
tional, protruding his tongue when requested, and ordinarily answering 
questions correctly, but he constantly mistook his mother, who was always 
at his bedside, for another person. Severe active delirium is commonly 
preceded by intense headache. In favorable cases the delirium is usually 
short, but in the unfavorable it is apt to continue with little abatement till 
coma supervenes. 

On account of the pain and disordered state of mind, patients seldom 
remain quiet in bed, unless they are comatose, or the disease is mild, or so 
far advanced that muscular movements are difficult from weakness. In 
severe cases they are ordinarily quiet a few moments as if slumbering, and 
then, aroused by the pain, roll or toss from one part of the bed to another. 
One of my patients, a boy of five years, repeatedly made the entire circuit 
of the bed during the spells of restlessness. In mild cases patients lie 
quiet, usually with their eyes closed, except when disturbed. 

All writers record a general hyperesthesia of the skin. Few patients 
that are not in a state of profound coma are free from it during the first 
weeks, and it increases materially the suffering. Frictions upon the sur- 
face, and even slight pressure with the fingers upon certain parts, extort 
cries. Gently separating the eyelids for the purpose of inspecting the 
eyes, and moving the limbs, or changing the position of the head, evidently 
increase the suffering, and are resisted. I have sometimes observed such 
outcries from slowly introducing the thermometer into the rectum, that I 
was forced to believe that the anal, and perhaps rectal, surface was also 
hypersensitive. The hyperesthesia has diagnostic value, for there is no 
disease with which cerebro-spinal fever is likely to be confounded in whicli 
it is so great. It is due to the spinal meningitis, and is appreciable even 
in a state of semi-coma. 

Tonic contraction of certain muscles, or groups of muscles, ispresent in 
all typical cases. In a small proportion of patients it is absent, or is not a 
prominent symptom, namely, in those in whom the encephalon is mainly 
involved, the spinal cord and meninges being but slightly affected, or not 
at all. This contraction is most frequent and marked in the muscles of 
the nucha, causing retraction of the head, but it is also common in the 
posterior muscles of the trunk, producing opisthotonos, and in less degree 



SYMPTOMS 



305 



in those of the abdomen and lower extremities, and hence the flexed posi- 
tion of the thighs and legs, in which patients obtain most relief. The 
muscular contraction is not an initial symptom. I have ordinarily first 
observed it about the close of the second day, but sometimes as early as the 
close of the first day, and in other instances not till the close of the third 
day. Attempts to overcome the rigidity, as by bringing forward the 
head, are very painful, and cause the patient to resist. In young chil- 
dren having a mild form of the fever with little retraction of the head, 
the rigidity is sometimes not easily detected. I have been able in these 
cases to satisfy myself and the friends of its presence, by observing the 
difficulty with which the head is brought forward on presenting to the 
patient a tumbler with cold water, which is craved on account of the thirst. 
The usual position of the patient in bed is with the head thrown back, 
the thighs and legs flexed, with or without forward arching of the spine 
(see figure). The muscular contraction continues from three to five weeks, 

Fig. 15. 




more or less, and abates gradually; occasionally it continues much longer. 
Through the kindness of Dr. Griswold, of Thirtieth Street, I was allowed 
to see an infant of seven months in the tenth week of the disease. It 
exhibited great fretfulness, decided prominence of the anterior fontanelle, 
probably from intracranial serous effusion, and. marked rigidity of the 
muscles of the nucha with retraction of the head. 

Paralysis occasionally occurs, but is less frequent than we would be led 
to expect from the nature of the lesions. It may occur early, but it is 
more frequently a late symptom. It may be limited to one or two of the 
limbs, as a leg, or arm and leg, or it may be more general. Thus a man 
treated by Dr. Law in the Dublin epidemic of 1865 could move neither 
arms nor legs, and TVunderlich saw a patient who had paralysis of both 
lower extremities and a considerable part of the trunk. As the paralysis 
is due to inflammatory processes in the cerebro-spinal axis, it usually dis- 
20 



306 CEREBRO-S PINAL FEVER. 

appears in a few weeks as the inflammation abates, and convalescence is 
established, but it may be more protracted. Thus in Wunderlich's case 
there was only partial recovery after the lapse of five months. 

Digestive System. — The tongue is ordinarily lightly covered with a 
whitish fur. Occasionally in cases attended with great prostration the 
fur is dry and brown, but only for a few days, when the moist whitish 
fur succeeds. The habitual brownish and dry fur on the tongue, and 
sordes upon the teeth, so common in typhus and typhoid fevers, are seldom 
observed in uncomplicated cases of this disease. Vomiting, which 1 have 
described as an initial symptom, usually ceases in a few hours, or not 
till the lapse of several days, and it frequently recurs at intervals during 
the periods of recrudescence, which are common in the progress of the 
fever. 

It occurs with little effort, often like a regurgitation, as is common when 
this symptom has a cerebral origin. The ejecta consist at first of the con- 
tents of the stomach and afterwards partly of bile. It does not differ as 
a symptom from the vomiting which is so common in sporadic meningitis. 
Having a similar origin is a sensation of faintness or depression referred 
to the epigastrium. 

The appetite is poor or entirely lost during the active period of the 
malady, and it is not fully restored till convalescence is well advanced. 
On account of the imperfect nutrition, patients progressively waste, and 
when the case is protracted there is notable emaciation. Thirst, already 
alluded to, and more or less constipation are common, but the latter read- 
ily yields to purgatives. On the other hand, diarrhoea sometimes pre- 
cedes, and accompanies the disease. I observed this in a few instances 
in 1872, when the weather had become warm. The patients were young 
children. 

Pulse The pulse in children is constantly accelerated. Even in 

mild cases it is rarely below 100 per minute, and its ordinary range is from 
112 to 160. I have seventy-five recorded observations of the pulse in 
children who recovered, taken before there was any decided improvement. 
The maximum pulse in these observations was 168 per minute, which was 
on the first day ; the minimum 82, and the average 123. The more severe 
and dangerous the attack, the greater the frequency of the pulse, unless 
occasionally in the comatose state. But even in profound coma the pulse 
was in my observations accelerated, and as death grew near, however great 
the stupor, it was progressively more frequent and feeble. Intermissions 
in the pulse do not seem to be as frequent as in sporadic meningitis. The 
pulse is liable to daily variations in frequency, which occur suddenly and 
without appreciable cause. The following consecutive enumerations of the 
pulse in four favorable cases which I have selected as typical will give an 
idea of these variations. 



TEMPERATURE. 307 

1st case, an infant of 14 months, 168, 120,108, 120, 140, 150, 136, 128, 
120. 

2d case, an infant of 2 years, 136, 152, 130, 132, 136, 140, 152, 140, 
136, 148. 

3d case, a boy of 6 years, 120, 120, 88, 84, 92, 124, 128, 120. 

4th case, a girl of 4 years, 116, 100, 124, 116, 120, 136, 140, 128, 128, 
104. 

I have preserved observations of this symptom made daily in nine fatal 
cases, and these show similar fluctuations in the frequency of the heart's 
contractions. The patients were children, all dying comatose. The maxi- 
mum pulse in these observations was 204, which was on the first day ; the 
minimum 88, and the average 140. The following are the consecutive 
enumerations of the pulse usually made twice daily in two of these cases. 
It will be seen that there was not only greater frequency of the pulse, but 
fluctuations from day to day similar to those in the favorable cases : — 

1st case, age 8 months, 204, 164, 116, 160, 164. 

2d case, age 2 years 8 months, 192, 168, 200, 152, 160. 

In most inflammatory and febrile diseases exacerbations commonly 
occur in the latter part of the day, but in this disease they do not seem 
to be influenced by the time of day, so that sometimes the temperature is 
highest and pulse most frequent in the morning, sometimes in the evening, 
and then again at midday. 

In favorable adult cases the pulse often remains under 100, and in cer- 
tain patients it scarcely has more than the normal frequency, but if the 
type is severe it rises to 110, 120, or over. In the adult, as in the child, 
as death approaches, the pulse becomes more and more frequent and feeble, 
and it seldom even in the most asthenic cases has the fulness and force ob- 
served in idiopathic inflammations. 

Temperature Certain of the older observers before the day of clini- 
cal thermometry asserted that the temperature is not increased. North 
remarked as follows : " Cases occur, it is true, in which the temperature is 
increased above the normal standard, but these are rare ;" and Foot and 
Gallop made similar statements. I am surprised also that some of the 
recent writers state that febrile movement is often absent. Thus, in a 
well-written American treatise, bearing the date 1873, it is stated " that 
febrile symptoms do not necessarily belong to epidemic cerebro-spinal men- 
ingitis as a substantive disease, for it may and not unfrequently does occur 
without exhibiting any such symptoms." (Lidell.) 

I have no doubt from the nature of cerebro-spinal fever, and from ther- 
mometric examinations, which I have made now in more than fifty cases, 
that there is always an elevation of the internal temperature above the 
normal standard during the active period of the disease. I have never 
observed a temperature of less than 99-J° if the examination were made 
within the first fourteen davs, and the reason that certain other observers 



308 CEREBRO-SPINAL FEVER. 

state differently is probably because they have taken the temperature of 
the cutaneous surface, which is very fluctuating and is often much below 
that of the blood. The temperature should be ascertained per rectum 
where it corresponds pretty nearly with that of the blood! In one instance 
I supposed that I had met a case in which the temperature was not ele- 
vated, and I cite it as showing the liability to error in the thermometric 
examinations of tliese cases : A female patient, forty-seven years old, three 
days sick and comatose, whom I was allowed to examine with the family 
physician, exhibited no elevation of temperature when the instrument was 
placed in the mouth and the axilla, but on introducing it into the rectum 
it rose to 991°. 

The internal temperature, although uniformly elevated, undergoes greater 
and more sudden variations than occur in any other febrile or inflammatory 
disease. These fluctuations, which correspond with similar changes in the 
pulse, are observed during the different hours of the same day. I have in 
the statistics of my practice 146 observations of the temperature in 35 pa- 
tients taken before the close of the second week. The highest I have already 
stated in speaking of the mode of commencement, namely 107§° in a child 
of two years. It fell a little subsequently, but rose again on the third day 
to 107°, when she died. In two other cases the temperature was 106° on 
the first day, and it did not afterwards reach so high an elevation. One 
of these died on the ninth day, and the other in the ninth week. The 
next highest temperature was 105|°, also on the first day, in an infant of 
■eight months, who died on the ninth day. The first and last of these 
cases occurred in an old wooden tenement-house in the suburbs of the 
city and upon an elevated outcropping of rock. Wunderlich has recorded 
a temperature of 110° in one or two cases, but so great an elevation must 
be very rare in cerebro-spinal fever, and is of course prognostic of an un- 
favorable ending. 

The external temperature undergoes similar but greater fluctuations, 
rising above and falling below the normal standard several times in the 
course of the same day. Similar fluctuations occur in sporadic meningitis, 
but they are much less pronounced. The more grave the case in those 
not comatose, the greater these variations. The following is a common 
example : the patient was two years old, and the case was one of consider- 
able severity. The observations were made at four consecutive visits dur- 
ing the first week. The internal temperature varied from 101^° to 104|° 
as the extremes, while that of the fingers and hand at the first examina- 
tion was 90^°, at the second 90°, at the third 103°, and at the fourth 83°. . 
Thus the temperature of the extremities at the first and second examina- 
tions was about 8° below that of health, while at the third examination it 
had risen 13°, so as nearly to equal the internal temperature, and at the 
fourth examination it had again fallen 20°, or 15-J- below the normal 
standard. The patient recovered. These sudden and great variations in 



CUTANEOUS SURFACE. 309 

the pulse and temperature have considerable diagnostic value in obscure 
and doubtful cases. 

Respiratory System The symptoms which are referable to the 

respiratory apparatus are for the most part quite subordinate except when 
an inflammatory complication occurs. The respiration in uncomplicated 
cases is quiet and easy, and a cough if present is usually slight and acci- 
dental. Intermittent, sighing, or irregular respiration is less frequent 
in cerebro-spinal fever than in sporadic meningitis, but it does occur. In 
ordinary cases the respiration is somewhat accelerated, but without any 
marked disturbance in its rhythm. In 31 observations in children who 
had the disease without complication, I found the average respirations 
42 per minute, while the average pulse was 137. It is seen therefore 
that the respiration as compared with the pulse was proportionately more 
frequent than in health. This appears to be due to the fact, that certain 
muscles, which are concerned in respiration, as the abdominal and per- 
haps others, are embarrassed in their movements by the tonic contrac- 
tions. In cases of pulmonary congestion, oedema, or inflammation, of 
course, the symptoms of this affection are superadded to those of the pri- 
mary disease. 

Cutaneous Surface The features may be pallid, of normal appear- 
ance, or flushed in the first days of the disease ; but in advanced cases 
they are pallid, as is the skin generally. A circumscribed patch of deep 
congestion often appears, as in sporadic meningitis, upon some parts of 
them, as the cheek, forehead, and ear, and after a short time disappears. 
Friction for a moment upon any part of the surfaee, when the tempera- 
ture is not reduced, produces the same appearance, a fact to which Trous- 
seau and others have called attention as regards sporadic meningitis. 

The following are the abnormal appearances of the skin which I have 
most frequently observed : 1st. Papilliform elevations, due to contraction 
of the muscular fibres of the corium, namely the so-called goose-skin. This 
is not uncommon in the first weeks. 2d. A dusky mottling, also common 
in the first and second weeks, in grave cases, and most marked where 
the temperature is reduced. 3d. Numerous minute red points over a large 
part of the surface, bluish spots a few lines in diameter due to extravasa- 
tion of blood under the cuticle, resembling bruises in appearance, and 
large patches of the same color, an inch or more in diameter, less common 
than the others, and usually not more than two or three upon a patient. 
These last I believe from certain observations are sometimes the result of 
bruises, which the patients receive during the times of restlessness. 4th. 
Herpes. This is common. It sometimes occurs as early as the second or 
third day, but in other instances not till towards the close of the first week 
or in the second. The number of herpetic eruptions varies from six or 
eight to a dozen or more. This affection evidently has a neuropathic ori- 
gin, the vesicles occurring chiefly on those parts of the surface which are 



310 CEREBRO-SPINAL FEVER. 

supplied by branches of the fifth pair of nerves. Its most common seat is 
upon the lips, but I have occasionally observed it upon the mucous mem- 
brane of the nasal and buccal surfaces, upon the cheek, around the ears and 
upon the scalp. 

During the first days the skin is apt to be dry. Afterwards perspira- 
tions are not unusual, and free perspirations sometimes occur especially 
about the head, face, and neck. The quantity of urine excreted is normal, 
or it may be in excess of the normal amount. It occasionally contains a 
moderate amount of albumen, and in exceptional instances cylindrical 
casts and blood-corpuscles. A deposit of urates in the urine is not infre- 
quent, but this so often occurs in inflammatory and febrile diseases, that it 
is of little moment. 

Arthritic inflammation, apparently of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an oede- 
matous appearance around one or more joints. Thus, in one case which 
came under my notice, and which was subsequently fatal, the parents, 
who were poor, and were therefore without medical advice till the case 
was somewhat advanced, had already diagnosticated rheumatism on ac- 
count of puffiness, which they had noticed around one of the wrists. 

The organs of the special senses are more or less involved in most cases, 
and the eye and ear are not infrequently the seat of serious lesions. Taste 
and smell are rarely affected, so far as known, but it is possible that they 
may sometimes be perverted or even temporarily lost during the time of 
greatest stupor. In one case at least the smell in one nostril was entirely 
lost. The affections of the eye and ear are the most important and inter- 
esting of those of the special senses. Strabismus is common. It may 
occur at any period of the fever, continuing a few hours or several days, 
and it may appear and disappear several times before convalescence is 
established. Occasionally it continues several weeks, but with few ex- 
ceptions the parallelism of the eyes is finally restored. In a boy of five 
years, whom I last saw three months after convalescence, there was still 
convergent strabismus of the right eye and double vision. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of com- 
mencement. These are dilatation, less frequently contraction, oscillation, 
inequality of size, feeble response to light, etc. Most patients present one 
or more of these abnormalities of the pupils, and they continue during the 
first and second weeks, and gradually abate as the condition of the patient 
improves. Inflammatory hyperemia of the conjunctiva often occurs. It 
commences early, and, now and then, the conjunctivitis is so intense, that 
considerable tumefaction of the lids occurs, with a free muco-purulent se- 
cretion. The false diagnosis has indeed been made of purulent-ophthalmia, 
in cases in which this affection of the lids was early and severe. But 
such intense inflammation is quite exceptional. More frequently there 



ORGANS OF THE SPECIAL SENSES. 311 

is a uniform diffused redness of the conjunctiva, not so dusky as in typhus, 
and the injected vessels cannot be so readily distinguished as in that 
disease. 

In certain cases almost the whole eye (all, indeed, of the important con- 
stituents) becomes inflamed ; the media grow cloudy, the iris discolored, 
and the pupils uneven and filled up with fibrinous exudation. The deep 
structures of the eye cannot, therefore, be readily explored by the oph- 
thalmoscope, but they are observed to be adherent to each other, and cov- 
ered by inflammatory exudation. They present a dusky red, or even a 
dark color, when the inflammation is recent. Exceptionally, the cornea 
ulcerates, and the eye bursts, with a loss of more or less of the liquids and 
shrinking of the eye. But ordinarily no ulceration occurs, and, as the 
patient convalesces, the cedema of the lids, hyperemia of the conjunctiva, 
the cloudiness of the cornea, and of the humors, gradually abate, and the 
exudation in the pupils is absorbed. The iris bulges forward, and the 
deep tissues of the eye. viewed through the vitreous humor, which before 
had a dusky red color from hyperemia, now present a dull white color. 
The lens itself, at first transparent, after awhile becomes cataractous. 
Sight is lost, totally and forever. This form of ophthalmia is sometimes 
rapidly developed, as in the following example : — ■ 

On July 5th, 1873, I was called to a boy, five years of age, who had 
reached the tenth day of cerebro-spinal fever without apparently any 
affection of the eyes, as both presented the normal appearance. On the 
following day the left eye was red and swollen from the inflammation and 
chemosis, so that the lids could not be closed, and the media were cloudy. 
Death occurred on the same day. 

If the patient live, the volume of the eye diminishes, as the inflamma- 
tion abates, to less than the normal size, even when there has been no 
rupture, and divergent strabismus is apt to occur. Professor Knapp, 
whose description of the eye I have for the most part followed, says : 
" The nature of the eye affection is a purulent choroiditis, probably metas- 
tatic." Fortunately so general and destructive an inflammation of the 
eye, as has been described above, is comparatively rare. On the other 
hand, conjunctivitis of greater or less severity, and hyperemia of the 
optic disk, consequent on the brain disease, are not unusual, but they 
subside, leaving the function of the organ unimpaired. 

Inflammation of the middle ear of a mild grade, and subsiding without 
impairment of hearing, is common. The membrana tympani, during its 
continuance, presents a dull yellowish, and in places a reddish, hue. Oc- 
casionally a more severe otitis media occurs, ending in suppuration, per- 
foration of the membrana tympani, and otorrhoea, which ceases after a 
variable time. But otitis media is not the most severe affection of the 
sense of hearing. Certain patients lose their hearing entirely and never 
regain it, and that, too, with little otalgia, otorrhcea, or other local symp- 



312 CEREBROSPINAL FEVER. 

toms, by which so grave a result can be prognosticated. This loss of 
hearing does not occur at the same period of the disease in all cases. 
Some of those who become deaf are able to hear- as they emerge from the 
stupor of the disease, but lose this function during convalescence, Avhile 
the majority are observed to be deaf as soon as the stupor abates and full 
consciousness returns. 

Two important facts have been observed in reference to the loss of hear- 
ing in these patients, namely, it is bilateral and complete. When first 
observed it is in some, as stated above, complete, but in others partial, and 
when partial it gradually increases till after some days or weeks, when it 
becomes complete. I have the records of ten cases of this loss of hearing, 
or about one in ten of the total number of cases which have either come 
under my observation, or have been reported to me by physicians in whose 
practice they occurred. One was a young lady, and the others children 
under the age of ten years. Prof. Knapp has examined thirty-one cases. 
" In all," says he, " the deafness was bilateral, and with two exceptions, 
of faint perception of sound, complete. Among the twenty- nine cases of 
total deafness there was only one who seemed to give some evidence of 
hearing afterwards." 

One theory attributes the loss of hearing to inflammatory lesions, either 
at the centre of audition within the brain, or in the course of the auditory 
nerves before they enter the auditory foramina. Thus Stille says : "This 
symptom appears to depend chiefly upon the pressure of the plastic exuda- 
tion in which the nerves are imbedded." The other theory attributes the 
loss of hearing to inflammatory disease of the ear, and especially of the 
labyrinth. Dr. Sanderson, who is an advocate of this latter theory, re- 
marks as follows : "As regards the nature of the affection, there appears to 
be good reason for believing that, like the blindness observed under similar 
circumstances, and sometimes in the same cases, it is dependent on inflam- 
matory changes in the organ of hearing . itself. Dr. Klebs was kind 
enough to show me in the pathological museum of the Charite, at Berlin, 
a preparation of the internal ear of a soldier who had died of epidemic 
meningitis complicated with deafness, in which fibrinous adhesions existed 
between the bones of the internal ear and the walls of the vestibule. Dr. 
Klebs stated that in the recent state the mucous lining of the vestibule 
was detached." In the case of a young woman who was deaf from the 
commencement and died on the eighth day, " both tympana were natural, 
but in the left membrana tympani was found a dense white thickening as 
large as a pin's head. On the same side the lining membrane of the 
semicircular canals was distinctly thickened and loosed, and in the ante- 
rior canal there was semifluid purulent masses." Professor Knapp also 
states : " The nature of the ear disease is, in all probability, a purulent 
inflammation of the labyrinth." According to him no disease of the 
middle ear could cause such complete deafness, and, as evidence that the 



NATURE. 313 

deafness is not due to central disease, Dr. Gruening obtained by electri- 
zation the normal reaction of the auditory nerve within the cranium. 
Moreover, if the lesion which destroys hearing is within the cranium, why 
is not the function of the other cranial nerves also abolished. Drs. Keller 
and Lucae have also, in three post-mortem examinations, found evidences 
of disease of the labyrinth. 

An argument in support of the former of these theories is the fact, that 
the lesion which produces the deafness is not ordinarily attended by any 
marked subjective symptoms referable to the ear, as otalgia, etc. Again, 
the fact that the deafness is always bilateral and simultaneous in the two 
ears, comports better with the doctrine of a central lesion than with that 
which locates the lesion in the ear. But the true theory can only be posi- 
tively established by dissections, and as we have sien, several post-mortem 
examinations have revealed inflammatory disease of the labyrinth in those 
who have died having this form of deafness, while in no case, so far as I 
am aware, has the ear been found free from inflammatory lesions. There- 
fore, the theory which ascribes the deafness to disease of the ear is much 
better established than the other, and in the present state of our knowl- 
edge we must accept it. Moreover, most of the aurists of this city, who 
have had excellent opportunities to examine these cases, believe in this 
theory. 

Nature If we examine the literature of cerebro-spinal fever we will 

find that three theories relating to its nature have been advocated : one 
that it is a local disease, occurring epidemically ; the second, that it is 
akin to typhus fever, or is a form of it ; and the third, that it is a disease 
sui generis. 

The first theory, that it is an epidemic local disease, once had many 
adherents, but it is now nearly discarded. Job Wilson, in 1815, consid- 
ered it a form of influenza, and he could discern no utility in drawing a 
distinction between spotted fever and influenza. We, in this day, can see 
no resemblance between the two, except that they are both pandemics. 
A more plausible view is, that it is merely an epidemic inflammation of 
the cerebral and spinal meninges. Even Niemeyer says that it presents 
no symptoms except such as are referable to the local affection. But a 
moment's thought will show us that cerebro-spinal fever differs as widely 
from simple meningitis, as scarlet fever with its pharyngitis differs from 
idiopathic pharyngitis. Cerebro-spinal fever begins abruptly, usually in 
those with previous good health ; and its initial symptoms, we have seen, 
are severe; while sporadic meningitis ordinarily occurs in those of feeble 
or failing health, with an insidious approach, and with gradually increasing 
symptoms. And though the two diseases have many symptoms in common, 
they differ in others. Scantiness of the urine, dryness of the skin, and 
retraction of the abdomen, are observed in sporadic meningitis, while a 
normal or increased amount of urine, a normal or even rounded fulness 



314 CEREBRO-SPINAL FEVER. 

of the abdomen, and often, also, perspiration, are symptoms of cerebro- 
spinal fever. The two diseases differ also strikingly as regards the periods 
of greatest danger and the prognosis; but the conclusive proof that the 
disease of which we are treating is not a local affection, but constitutional, 
with local manifestations, is found in the fact of a constant and early blood 
change, which in all severe cases is manifested by the appearance of the 
skin, and in other ways. 

Cerebro-spinal fever differs widely in many particulars from typhus, 
although it is probable that it was confounded with it previously to the 
present century, and many even now consider it a form of that disease. 
Their theory is, that from some unknown cause or influence the poison of 
the constitutional disease acquires for the time an affinity for the great 
nervous centres, producing their congestion and inflammation, just as that 
of scarlet fever causes a pharyngitis, and if we could detach from it these 
local manifestations, we would have a malady which differs but little, if at 
all, in its clinical history and nature, from typhus. 

The following are some of the differences which, in my opinion, not 
only establish the non-identity of these two fevers, but show that there is 
no close relationship between them. The causes of typhus are deter- 
mined. Crowding, personal uncleanliness, and imperfect ventilation are 
sufficient to produce it in any season or climate. Such is not the case 
with cerebro-spinal fever. The most that can be said of the agency of 
these and similar anti-hygienic conditions in causing this fever is, as we 
have already stated, that they produce deterioration in the tone of the 
system, so that it is less capable of resisting the prevailing epidemic influ- 
ence. The cause of cerebro-spinal fever occurs independently of the 
usual conditions of life, and is present or operative only at long intervals ; 
else the epidemic would not be so rare. Typhus is highly contagious ; 
cerebro-spinal fever is not contagious, or is feebly so. Typhus is rare 
under the age of ten years, and is most frequent in youth and manhood, 
while the reverse is true of cerebro-spinal fever. Typhus commences with 
mild or moderately severe symptoms, which increase in severity day by 
day, and the period of greatest danger is therefore at an advanced stage 
of the disease. Contrast this with the violence of the initial symptoms of 
cerebro-spinal fever, and the fact that the first and second days are most 
perilous. Moreover, typhus does not seem to be more prevalent during 
epidemics of cerebro-spinal fever than at other times. 

If we pass over those many symptoms due to lesions of the cerebro- 
spinal axis, which are present in cerebro-spinal fever, but are absent in 
typhus fever, there are other points of dissimilarity which cannot be satis- 
factorily explained, except on the supposition of an essential difference in 
the two diseases. The sordes on the teeth and gums, dry and brown fur 
upon the tongue, peculiar mouse-like odor, and more definite duration of 
typhus, are points of contrast with cerebro-spinal fever. Moreover, and 



PROGNOSIS. 315 

as, in my mind, very conclusive evidence of the non-identity of typhus 
and cerebro-spinal fever, that common lesion of the former, namely, en- 
largement and softening of the spleen, is seldom present in the latter. 
The spleen has usually been found normal or moderately congested in most 
post-mortem examinations of cerebro-spinal fever. 

Where, therefore, should cerebro-spinal fever be placed in the catalogue 
of diseases ? It resembles scarlet fever in the suddenness and violence of 
its onset ; sporadic meningitis on the one hand, and typhus on the other, 
as we have seen, in many of its symptoms ; influenza and cholera, in the 
infrequency of its visitations, and its pandemic nature. But the particu- 
lars in which it differs from these diseases are more numerous and important 
than those in which it resembles them. Like a rare object in nature, which 
naturalists are not able to classify with others on account of dissimilarities, 
though it has its resemblances to more than one, cerebro-spinal fever ap- 
pears to stand alone, as a peculiar constitutional disease, having a peculiar 
but obscure cause, and a dangerous manifestation or expression located in 
the cerebro-spinal system. 

Prognosis Cerebro-spinal fever is justly one of the most dreaded of 

the epidemic diseases, on account of the great mortality which attends it, 
and the fact that those who survive are often left with some incurable ail- 
ment. The following are the statistics of fifty-two cases, most of which 
occurred in my own practice, and the rest I visited in consultation ; twenty- 
six were cured and twenty-six died. Sixteen of the twenty-six who died 
were profoundly and hopelessly comatose within the first seven days, most 
of them dying within that time, and some even on the first and second 
days, while others lingered into the second week and died without any 
sign of returning consciousness. These statistics therefore show, and the 
same is true of the statistics of other observers, that the first week is the 
time of greatest danger, and if no fatal symptoms are developed during 
this week recovery is probable. Only three deaths occurred after the 
twenty-first day, one from purpura hemorrhagica, the hemorrhages taking 
place from the mucous surfaces, and the other two after a sickness of more 
than two months, in a state of extreme emaciation and prostration. In 
these last cases muscular tremors and convulsions preceded death. The 
ten who subsequently died, but did not become comatose during the first 
week, were nevertheless seriously sick from the first day, but there was hope 
and some expectation of a different issue till near death. 

There is probably no disease which falsifies the predictions of the physi- 
cian more frequently than this. This is due partly to the severity of the 
cerebral symptoms in the commencement, which, did they occur in the 
common forms of meningitis, with which he is more familiar, would justify 
an unfavorable prognosis, and partly to the remissions and exacerbations, 
the occurrence alternately of symptoms of apparent convalescence and 
recrudescence, or relapse, which characterizes the course of this disease. 



316 CEREBRO-SPINAL FEVER. 

Grave initial symptoms, which might seem to have a fatal augury, are 
often followed by such a remission, that all danger seems past, and in a 
few hours later perhaps the symptoms are nearly or quite as grave as at 
first. 

Under the age of five years, and over that of thirty, the prognosis is less 
favorable than between these ages. An abrupt and violent commencement, 
profound stupor, convulsions, active delirium, and great elevation of tem- 
perature are symptoms which should excite solicitude, and render the prog- 
nosis guarded. If the temperature remain above 105° death is probable, 
even with moderate stupor. Numerous and large petechial eruptions show 
a profoundly altered state of the blood, and are therefore a bad prognostic, 
and so is continued albuminuria, as it indicates great congestion of the kid- 
neys, associated probably with other internal congestions. In one case, a 
boy, which I had an opportunity of examining nearly a year after the at- 
tack, the kidneys were still affected. There was anasarca of the face and 
extremities with albuminuria. The renal congestion had apparently de- 
generated into a chronic Bright's disease. The result of the case I have 
not ascertained. Profound stupor, though a dangerous symptom, is not 
necessarily fatal as long as the patient can be aroused to partial conscious- 
ness, and the pupils are reponsive to light. So long as it does not pass 
into actual coma, it is less dangerous than active or maniacal delirium, 
which is apt to eventuate in this coma. 

A mild commencement, with general mildness of symptoms, as the ability 
to comprehend and answer questions, moderate pain and muscular rigidity, 
some appetite, moderate emaciation, little vomiting, etc., justifies a favor- 
able prognosis, but even in such cases it should be guarded till convales- 
cence is fully established. 

Death in the first stages of cerebro-spinal fever appears to occur ordi- 
narily from coma, but we will see from the lesions that congestion of the 
posterior portions of the lungs is frequent, and Sanderson says : — 

" In all the fatal cases which came under my notice, the most prominent- 
symptoms, which preceded death, were those which indicate impairment 
and perversion of the respiratory functions. As the breathing became more 
hurried and difficult, the general depression became more intense, the 
pulse became weaker and quicker, and the temperature of the skin more 
elevated.". 

He cites the case of a child, who died in that way, but was at the same 
time comatose. In more protracted cases in which there is softening of 
portions of the cerebro-spinal axis, or fibrino-purulent collections around 
it, which are not absorbed, death may occur either from convulsions and 
coma, or from exhaustion. We have already alluded to one case in which 
purpura hemorrhagica was developed, and the child was exhausted by the 
hemorrhages. 

Those who fully recover often exhibit symptoms usually of a nervous 



ANATOMICAL CHARACTERS. 317 

character, as irritability of disposition, headache, etc., for months after 
convalescence is established. 

Diagnosis Cerebro-spinal fever, on account of the nature and severity 

of its symptoms and the suddenness of its onset, may be mistaken for scar- 
latina, and vice versa. In one instance, to my knowledge, this mistake 
was made. High febrile movement, vomiting, convulsions, and stupor, 
.are common in the commencement of scarlet fever, and we have seen that 
the same symptoms ordinarily usher in the severer forms of cerebro-spinal 
fever. It will aid in diagnosis to ascertain whether there is redness of the 
fauces, for this is present in the commencement of scarlet fever, and in a 
few hours later the characteristic efflorescence appears upon the skin. 

The diagnosis of cerebro-spinal fever from the common forms of menin- 
gitis is ordinarily not difficult, for while in the former there is the maximum 
intensity of symptoms on the first day, in the latter there is a gradual and 
progressive increase of symptoms from a comparatively mild commence- 
ment. Moreover cases of ordinary or sporadic meningitis occurring at the 
age when cerebro-spinal fever is most frequent, are commonly secondary, 
being due to tubercles, caries of the petrous portion of the temporal bone, 
or other lesion, and there are, therefore, in these cases preceding and 
accompanying symptoms, which are directly referable to the antecedent 
disease. We have seen how different the case is with cerebro-spinal 
fever, which in most patients begins abruptly in a state of previous good 
health. Again in cerebro-spinal fever, after the second or third day, 
hyperesthesia, retraction of the head, and other characteristic symptoms 
occur, which are either not present, or are much less pronounced, in 
ordinary meningitis. The. symptoms of hysteria sometimes bear a close 
resemblance to the delirium observed in certain cases of cerebro-spinal 
fever. But the thermometer enables us to make the diagnosis, for in 
hysteria there is no febrile movement. In our remarks on the nature of 
cerebro-spinal fever we have sufficiently described the differences between 
this disease and typhus. 

Anatomical Characters I have notes of the post-mortem appear- 
ances in 7C> cases, published chiefly in British and American journals ; 29 
died within the first three days ; 28 between the third and twenty-first day ; 
8 died after the twenty-first day, and the duration of the remaining 11 was 
unknown. These records furnish the data for the following remarks : — 

The blood undergoes changes, which are due in part to the inflamma- 
tory, and in part to the constitutional and asthenic, nature of the disease. 
The proportion of fibrin is increased in cases that are not speedily fatal, 
as it ordinarily is in idiopathic inflammations. Analyses of the blood, 
published by Ames, Tourdes, and Maillot, show a variable proportion of 
fibrin from 3.40 to more than six parts in 1000. In sthenic cases accom- 
panied by a pretty general meningitis, cerebral and spinal, there is, after 
the fever has continued some days, the maximum amount of fibrin, while 



318 CEREBROSPINAL FEVER. 

in the asthenic and suddenly fatal cases, with inflammation slight, or in 
its commencement, the fibrin is but little increased. The most cDmmon 
abnormal appearance of the blood observed at autopsies is a dark color 
with unusual fluidity, and the presence of dark, soft clots. Exceptionally 
bubbles of gas have been observed in the large vessels and the cavities of 
the heart. An unusually dark appearance of the blood, small and soft 
dark clots, and the presence of gas bubbles, when only a few hours have 
elapsed after death, indicate a malignant form of the disease, in which 
this fluid is early and profoundly altered. In certain cases the blood is 
not so changed as to attract attention from its appearance. The points or 
patches of extravasated blood which are observed in the skin during life 
in a certain proportion of cases, usually remain in the cadaver. In incising 
them the blood is seen to have been extravasated, not only in the layers 
of the skin, but also in the subcutaneous connective tissue. Extravasa- 
tions of small extent are also sometimes observed upon the thoracic and 
abdominal organs. 

In those who die after a sickness of a few hours or days, namely, in the 
stage of acute inflammatory congestion, the cranial sinuses are found 
engorged with blood, and containing soft, dark clots. The meninges en- 
veloping the brain are also intensely hyperremic in their entire extent in 
most cadavers ; but in some, in certain parts only, while other portions 
appear nearly normal. In those cases which end fatally within a few 
hours, this hyperamia is ordinarily the only lesion of the meninges ; but 
if the case is more protracted, serum and fibrin are soon exuded from the 
vessels into the meshes of the pia mater, and underneath this membrane 
over the surface of the brain. Pus-cells also occur mixed with the fibrin, 
sometimes so few as to be discovered only by the microscope, but in other 
cases in such quantity as to be much in excess of the fibrin, and be readily 
detected by the naked eye. Pus, which in these cases, no doubt, consists 
of white blood-corpuscles which have escaped with the fibrin from the 
meningeal vessels, sometimes appears early in the disease. Thus, in the 
Dublin Quarterly Journal, 1866, Dr. Gordon relates the history of a case 
in which death occurred after a sickness of five hours, and a purulent- 
appearing greenish exudation had already occurred in places under the 
meninges. The exudation of fibrin commences also in the course of a few 
hours. Thus in a case of thirty hours' duration, published by Dr. William 
Frothingham, in the American Medical Times, April 30th, 1864, and in 
another of one day's duration, published by Dr. Haverty, in the Dublin 
Quarterly Journal for 1867, exudation of fibrin had already occurred in 
and under the pia mater. The arachnoid soon loses its transparency and 
polish, and presents a cloudy appearance over a greater or less extent of 
its surface. This cloudiness is greatest in the vicinity of the fibrinous exu- 
dation, but it occurs also where no such exudation is apparent to the naked 
eye. Dr. Gordon describes a case of only eight hours' duration, in which 



ANATOMICAL CHARACTERS. 319 

the arachnoid was already opaque at the vertex, but of normal appearance 
at the base of the brain {Dublin Quarterly Journal, 1866), though the 
vessels of the pia mater were everywhere greatly congested. 

The exudation, serous, fibrinous, and purulent, occurs, as in other forms 
of meningitis, within the meshes of the pia mater, and underneath this 
membrane over the surface of the brain. The fibrin is raised from the 
surface of the brain with the meninges. It is most abundant in the inter- 
gyral spaces around the course of the vessels, over and around the optic 
commissure, the pons Varolii, the cerebellum, medulla oblongata, and 
along the Sylvian fissures. It is most abundant in the depressions, where 
it sometimes has the thickness of T L to J of an inch, but it often extends 
over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges, as for example meningitis from 
tubercles, or caries of the petrous portion of the temporal bone, in both 
of which it is commonly limited to the base of the brain, or from accidents 
when the meningitis commonly occurs upon the side or summit of the 
brain. The meningitis of cerebro-spinal fever, on the other hand, having a 
general or constitutional cause, occurs with nearly equal frequency upon 
all parts of the meningeal surface, except that it is, perhaps, most severe 
in the depressions where the vascular supply is greatest. In cases of great 
severity, the inflammatory exudation, fibrinous, or purulent, or both, may 
cover nearly, or quite, the entire surface of the brain. Thus, in the case 
of a negro, 35 years old, only four days sick, whose body was examined at 
Bellevue Hospital on May 30th, 1872, the record states that there was a 
purulent exudation over the entire surface of the cerebrum and cerebellum. 
The quantity of serous exudation varies according to the duration and 
amount of congestion. In some the quantity is so small as scarcely to 
attract attention, but in other instances, especially when the disease is pro- 
tracted, it is large. In a case reported by Dr. Moorman in the Amer. 
Journ. of Med. Sci. for Oct. 1866, it is stated that about three pints of 
turbid serum escaped from the cranial cavity in attempting to remove the 
brain, but as there was no measurement the statement may be somewhat 
exaggerated. 

In those who die at an early stage of the disease, the vessels of the brain, 
like those of the meninges, are hypersemic, so that numerous " puncta vas- 
culosa" appear upon its incised surface. At a later period the hyperemia, 
like that of the meninges, may disappear. If there is much effusion of 
serum within the ventricles and over the surface of the brain, the convo- 
lutions are apt to be flattened, and the pressure may be such that the 
amount of blood circulating within the brain is reduced below the normal 
quantity. Thus, in the case of a child of three years, who lived sixteen 
days, and was examined after death by Burdon-Sanderson, the ventricles 



320 CEREBRO-SPINAL FEVER. 

contained a large amount of turbid serum, and the brain-substance was 
everywhere pale and anaemic. 

Cerebral ramollisse?ne?it occurs in certain cases. At one of the examina- 
tions in Charity Hospital, the patient having been only three days sick 
the brain was found much softened. The dissection was made seven hours 
after death, so that the softening could not have been the result of decom- 
position. At one of the post-mortem examinations in Bellevue Hospital, 
softening of the fornix, corpus callosum, and septum lucidum was observed ; 
and in another, softening in the neighborhood of the subarachnoid space. 
In a case related by Dr. Moorman in the Amer. Journ. of Med. Sci. for 
Oct. I860, it is stated that portions of the brain, medulla oblongata, and 
pons Varolii were softened. In a case observed by Dr. Upham, there 
was softening of the superior portion of the left cerebral hemisphere. 
Occasionally the whole brain is somewhat softened. Burdon-Sanderson, 
Russell, and Gil-hens, each relate such a case. Moreover the walls of the 
lateral ventricles are ordinarily more or less softened in these cases, as 
in the ordinary form of meningitis. In rare instances the brain is oecle- 
matous, as in a case published by Dr. Hutchinson in the Amer. Journ. oj 
Med, Sci. for July, 1866. In this case the patient was only four days 
sick, and the whole brain was oedematous, serum escaping from its incised 
surface. 

The ventricles contain liquid, in some patients transparent serum, in 
others serum turbid, and containing flocculi of fibrin or fibrin with pus. 
The liquid in the different ventricles as they intercommunicate is similar. 
The choroid plexus is either injected or it is infiltrated with fibrin and pus. 
In advanced cases with the abatement of the inflammation absorption 
commences. The serum obviously disappears soonest, and the pus and 
fibrin more slowly, by fatty degeneration and liquefaction. Still absorp- 
tion and the return of the brain and meninges to their normal state are 
slow, and hence the tediousness of convalescence. An infant, whom I 
was allowed to examine in the practice of another physician, took the dis- 
ease at the age of five months, and two months subsequently, great promi- 
nence of the anterior fontanelle and other symptoms indicated still the 
presence of a considerable amount of effusion within the cranium. No 
post-mortem examinations, so far as I am aware, have yet revealed the 
state of the brain and meninges in those who have had this disease at some 
former period and recovered from it, but it is not improbable that some 
opacity and preternatural adhesions in places may continue for life. 

The remarks made in reference to the cerebral, apply for the most part 
to the spinal meninges. There is at first intense hyperemia of the mem- 
branes usually over the entire surface of the cord, soon followed by fibrin- 
ous, purulent, and serous exudation, in the meshes of the pia mater, and 
underneath this membrane. Thickening and opacity of the meninges, and 
often adhesions, occur in protracted cases. The exudation is sometimes 



TREATMENT. 321 

confined to a portion of the meninges, more frequently that covering the 
posterior than anterior aspect of the cord, but it may occur in any part, 
and in severe cases the entire pia mater of the spine is infiltrated with it. 
The exudation may have the usual appearance of fibrin and pus, but it is 
sometimes greenish and sometimes bloodstained. Small extravasations 
of blood almost necessarily occur as a result of the intense hyperemia, 
and in one case related by Burdon-Sanderson it is stated that there was 
a layer of blood one-eighth of an inch thick over the whole cord below the 
bronchial swelling. In post-mortem examinations the central canal of the 
cord has usually been overlooked. Ziemssen relates a case, and Gordon 
another, in which it was dilated and filled with purulent fluid. The ana- 
tomical changes which have been observed in the cord itself have been in- 
jection of its vessels in recent cases, and occasional softening of portions. 
Thus, in a case which was examined in Bellevue Hospital, April 13th, 
1872, it is stated that there was softening of the cord in the upper part 
of the dorsal region. In most of the examinations the only abnormal ap- 
pearance observed in the cord was hyperemia, but in a considerable pro- 
portion of cases the records state that the substance of the cord appeared 
normal. 

Xo constant or uniform lesions occur in the organs of the trunk. The 
most common is congestion of the lungs, especially of the posterior por- 
tions, with more or less oedema, and nodules of hepatization or points of 
extravasation. Effusion of serum, sometimes bloodstained, occasionally 
occurs in the pleural and other serous cavities. The auricles and ventri- 
cles of the heart, as already stated, contain more or less blood, with soft 
dark clots in the more malignant and rapidly fatal cases, but larger and 
firmer in those which have been more protracted. The spleen, liver, kid- 
neys, stomach and intestines, one or more, are sometimes congested, but 
in other cases their appearance is normal. The absence of uniformity as 
regards the state of the spleen, the fact that in many patients it undergoes 
no appreciable change, is important, since this organ is so generally 
enlarged and softened in infectious diseases. The agminate and solitary 
glands have ordinarily been overlooked at post-mortem examinations, but 
in certain cases they have been found prominent. 

Treatment. Preventive Although we do not fully understand the 

conditions in which cerebro-spinal fever originates, it is certain, from facts 
observed in epidemics, that we are able to do something to diminish its 
severity and prevalence and to protect the community. Measures to this 
end must be of a twofold character, namely, such, in the first place, as are 
calculated to improve the surroundings of the individual, so as to conduce 
to a better state of health, and secondly, the regulation of his mode of 
life. Cleanliness and dryness of streets and domiciles, perfect drainage 
and sewerage, prompt removal of all refuse matter, avoidance of over- 
crowding, so as to procure the utmost salubrity in the atmosphere, the use 
21 



322 CEREBRO-SPINAL FEVER. 

of plain and wholesome food — in a word, the strict observance of sanitary 
requirements in all the surroundings — cannot fail to reduce the number 
and diminish the severity of cases ; for, as we have seen, this disease as- 
sumes its worst form and numbers the most victims where anti-hygienic 
conditions most abound. Of scarcely less importance is a strict surveil- 
lance of the mode of life, especially of children and young people, during 
the time of an epidemic. We have seen that this disease not infrequently 
follows irregularities in the mode of life, excesses of whatever kind, and 
fatigue, mental or bodily. These should therefore be avoided. A quiet 
mode of life and moderate exercise, plain and wholesome and regular 
meals, and the full amount of sleep, afford some, but not complete, security 
in the midst of an epidemic. 

Curative. — It will aid in determining the proper mode of treatment to 
bear in mind the anatomical characters as ascertained by post-mortem 
examinations. As the chief danger in the first days is from the intense 
inflammatory congestion of the cerebro-spinal axis, the prompt employ- 
ment of measures calculated to relieve this is of the utmost importance. 
To this end bladders or bags of ice should be immediately applied over 
the head and nucha, and constantly retained there during the first week. 
Bran mixed with pounded ice produces a more uniform coldness, and is 
more comfortable to the patient, than ice alone. Cold produces a prompt 
and powerful effect in diminishing the turgescence of the cerebral and 
meningeal vessels. A hot mustard foot-bath or general warm bath with 
mustard, should also be employed as early as possible, since it acts so 
powerfully as a derivative from the hyperaemic nerve-centres, tends to 
calm the nervous excitement and prevent convulsions. An enema to 
open the bowels is also proper. 

Should bloodletting be employed, especially in the more sthenic cases? 
Even in the commencement of the present century, when it was customary 
to bleed generally or locally in the treatment of inflammatory and febrile 
diseases, a majority of the American practitioners whose writings are ex- 
tant discountenanced the use of such measures in the treatment of this 
disease. Drs. Strong, Foot, and Miner, though under the influence of the 
Broussaian doctrine, were good observers, and they soon abandoned the 
use of the lancet and leeches in the treatment of these patients for more 
sustaining measures. Strong, who published a paper on spotted fever in 
the Medical and Philosophical Register, in 1811, states that certain phy- 
sicians employed venesection as a means of relieving the internal conges- 
tions, but finding that the pulse became more frequent after a moderate 
loss of blood, they soon laid aside the lancet. Some experienced physi- 
cians of that period, however, continued to recommend and practise deple- 
tion, general as well as local, as, for example, Dr. Gallop, who treated 
many cases in Vermont in the epidemic of 1811. 

No physician at the present time recommends venesection, but some of 



TREATMENT. 323 

the best authorities, as Sanderson and Niemeyer, approve of local bleed- 
ing in certain cases. It may be stated, as a safe rule, that leeches or other 
modes of local depletion should not be prescribed in a large majority of 
cases, and if prescribed in any case it should be on the first day, for on 
the first day the maximum of inflammatory congestion is attained, and in 
no case should more than a very moderate quantity of blood be abstracted. 
Blood should only, in my opinion, be abstracted, and in small quantity, 
from the temples or behind the ears, in the more sthenic cases, in which, 
after the prompt employment of the other measures recommended, the 
stupor becomes more and more profound, and the patient appears already 
in incipient coma. But in allowing a moderate depletion it must not be 
forgotten that the disease is in its nature asthenic, and in its subsequent 
course will require sustaining measures. It is apparent, however, that the 
abstraction of blood, if once allowed, is likely to be recommended too fre- 
quently in the treatment of this disease by those, who have had but little 
experience with it, for the state of most patients in the commencement 
seems so critical, and the stupor so great, that the most energetic measures 
seem to be required. But if the blood of patients is spared, and they are 
promptly and properly treated otherwise, it is surprising to see how many 
emerge from the stupor and finally recover. For example, in a case re- 
lated to me by Dr. Griswold, the patient seemed to be comatose for three 
days, being apparently unconscious and the pupils scarcely responding 
to light, but he recovered without losing blood. In only one case have I 
recommended the abstraction of blood, and this was so instructive that I 
will briefly relate it. 

M., a female, 4 years old, was seized at 2 A. M., March 7th, 1873, with 
vomiting, chilliness, and trembling, followed by severe general clonic con- 
vulsions lasting about fifteen minutes. On visiting her early in the morn- 
ing, I found her semi-comatose, with a pulse of 132, which in a few hours 
rose to 156; temperature 101 J°, respiration 44; eyes closed; pupils mode- 
rately dilated and responding feebly to light ; surface presenting a dusky 
mottling ; constant tremulousness, and frequent twitching of limbs. Four 
grains of bromide of potassium were ordered to be given every hour to 
two hours, with the usual local measures, namely, ice to the head and 
nucha, and a hot mustard foot-bath, followed by sinapisms to the extrem- 
ities. 

Stk. Pulse 136 ; is partly conscious when aroused, but immediately re- 
lapses into sleep ; head considerably retracted ; bowels constipated ; vomits 
occasionally; temperature 102°. Treatment, a leech to each temple, on 
account of the extreme stupor ; other treatment to be continued. 

9th. The leech-bites bled, though slowly, nearly five hours ; pulse 180, 
and so feeble as to be counted with difficulty ; temperature 101^°. The 
patient is evidently sinking. Treatment, a teaspoonful of Bourbon whiskey 
in milk every two hours, beef-tea and other nutritious drinks frequently, 
also the bromide at intervals. Evening, pulse 172, still feeble. 

10th. Pulse 180, barely perceptible ; great hyperesthesia ; temperature 



324 CEREBRO-SPINAL FEVER. 

of axilla 100°, of fingers and hand below 90° ; axes of eyes directed 
downwards. 

11th. Pulse still very feeble, varying from .160 to 228; temperature 
102^°. There has been no intermission in the use of the stimulants or 
nutriment night or day ; pupils moderately dilated and somewhat more 
sensitive to light. 

After this the patient gradually rallied for a time, so that the pulse 
became stronger and less frequent, but death finally occurred after nine 
weeks in a state of emaciation and extreme exhaustion. Slight convul- 
sions occurred in the last hours. 

It is seen that, after the loss of blood from two leech-bites, this patient 
passed into a state of extreme exhaustion so that for three days I did not 
believe that she would live from one hour to another, and death finally 
occurred. Although the loss of blood may have been useful in relieving 
the stupor, yet a worse danger resulted. Experience like this, which I 
believe corresponds with that of other observers, shows how seldom and 
with what caution the blood of the patient should be abstracted. 

The internal remedy most in favor with the profession of this city, in the 
first stage of this disease, and properly so, is the bromide of potassium, espe- 
cially in the treatment of children. Evidently a remedy is required which 
will diminish the calibre of the arterioles, and consequently the hyper- 
emia of the cerebro-spinal axis and its meningeal covering. Ergot has 
been-employed for this purpose, and in some instances with a satisfactory 
result ; but bromide of potassium, while it contracts the arterioles of the 
encephalon, is at the same time a powerful sedative to the nervous system. 
More than any other safe internal remedy, it prevents convulsions in chil- 
dren, which occurring in this disease add a passive to the already intense 
active congestion of the cerebro-spinal axis. This agent in medicinal 
doses produces no ill effect except when given frequently for a lengthened 
period, when it may produce muscular weakness. A child of five years may 
take five or six grains every two, three, or four hours, according to the 
urgency of the case. After the first week it should be given less frequently, 
and finally omitted. The practice of some physicians, who continue the 
use of the bromide in frequent large doses after the first or perhaps second 
week, is to be deprecated, since after a time it is apt to produce symptoms 
which can with difficulty be discriminated from those of cerebro-spinal 
fever. These are stated as follows'by Mr. Wood: " Great muscular de- 
bility, dimness of sight with dilated pupils, irregular gait, the patient 
reeling as though intoxicated, whilst nausea, vomiting, or purgation, with 
abdominal pain of a dull aching character, may also be present." (British 
Med. Journ., October 14th, 1872.) It is obviously better after the first 
week, if the symptoms are no longer urgent, to discontinue the bromide 
entirely, than to continue its use in such doses and for such a period that 
there may be danger of producing its physiological effects. Nevertheless 



TREATMENT. 325 

it is proper to resume its use during its periods of recrudescence which are 
so apt to occur at any stage of the disease. 

The bromide cannot be depended on to allay the pain, which often, on 
account of its severity, requires immediate treatment, and sometimes it 
does not allay the excessive agitation. For these symptoms an opiate 
is indicated, which in my practice has produced a much more satisfac- 
tory result than hydrate of chloral. Quite moderate doses are sufficient 
to produce the effect desired. A patient of six years was quieted by ^ 
part of a grain of sulphate of morphia. So useful are opiates in allaying 
pain in this disease, that some observers, as Niemeyer and Ziemssen, con- 
sider them the most valuable of the internal remedial agents which we 
possess, and the benefit from their use in these cases has certainly had 
considerable effect in disabusing the minds of physicians of the dread which 
they have entertained of their employment in acute affections of the brain. 
MannkofF and others have employed subcutaneous injections of morphia. 

Quinia is suggested as a remedy by the paroxysmal character of the 
pains and the fever, but I believe that I am sustained by the general ex- 
perience of physicians in this city in stating that it has very little effect 
upon either of these symptoms, or upon the course of the disease. I have 
employed it in small and large doses, as many as fifteen grains per day to 
a child of thirteen years, but am not aware that it has been of any service 
except as a tonic. There is perhaps no better remedy for the nausea than 
bismuth in large doses. 

Frequent counter-irritation along the spine by dry cups or an irrita- 
ting liniment is useful from the first, and vesication of the nucha by can- 
tharidal collodion or otherwise when the ice-bag is discontinued. Sus- 
taining measures should also be commenced early. Tonics, vegetable 
and ferruginous, should be administered after the disease has continued 
a few days, alternating with and finally superseding the bromide. I have 
in some cases employed the citrate of iron and ammonia. The diet must 
be nutritious, consisting of the meat broths, milk, etc., during the entire 
course of the malady. Most patients require alcoholic stimulants sooner 
or later. In cases presenting a feeble pulse, and other evidences of pros- 
tration, their early and continued employment is advisable, as in the 
case which I have related, in which whiskey was administered every two 
hours after the second day. The constipation is ordinarily best relieved 
by enemata. The room should be dark, of comfortable temperature, and 
quiet. 



326 ACUTE RHEUMATISM. 



CHAPTER V. 

ACUTE RHEUMATISM. 

Rheumatism is a constitutional disease with a local manifestation, 
namely, an inflammation of the sero-fibrous tissues, chiefly in and around 
the articulations, but occasionally in other parts. It is less frequent prior 
to than in the years succeeding puberty ; still, it is not uncommon in 
children after the fifth year. Under this age it is stated to be rare, but 
is probably not so infrequent as is commonly supposed. For while in the 
adult the diagnosis of rheumatism is easy, in children this disease is likely 
to be overlooked, if, as is true in a large proportion of cases in early life, 
the swelling and redness of the affected joints are slight, and only a few 
joints are inflamed. If there is cardiac inflammation, the articular affec- 
tion may be nearly absent, thus rendering the diagnosis more obscure. 
That rheumatism is not so very rare under the age of five years, I infer 
from the fact that we now and then meet with cases of valvular disease in 
children of this age or older, which, there can be little doubt, had its ori- 
gin in rheumatism, although the parents are not aware that there has ever 
been an attack of this disease. Such cases have not infrequently been 
brought to the children's class in the Outdoor Department at Bellevue. 
Thus, in January, 1871, a little girl, three years old, was presented, hav- 
ing distinct aortic direct, and mitral regurgitant murmurs. The mother 
was not aware that she had had rheumatism, but at the age of twenty 
months she had for several days pretty active febrile symptoms, which the 
physician attributed to some other ailment. In April, 1871, another girl, 
of the same age, was brought to the clinique, having a distinct mitral 
regurgitant murmur. The mother stated that she had been well till a 
month previously, when she was confined to her bed for a few days, hav- 
ing a high fever. She was attended by a homoeopathic physician, and the 
exact character of her sickness the mother was not able to state. Further 
medical advice was sought, as the child remained delicate, though her 
health was better than at first. There can be little doubt that the obscure 
fever in this case had been rheumatic. In another child treated else- 
where, not old enough to relate the subjective symptoms, there was, in 
addition to an intense fever, evident pain in one foot or leg, when the 
limb was moved. Still, the nature of the disease was not diagnosticated 
till some time after recovery, when a valvular murmur was accidentally 
discovered. Such histories, which I do not think are rare, show, if my 
opinion of them is correct, that rheumatism may occur not very rarely in 



CAUSES — SYMPTOMS. 327 

young children, even infants, for which purpose they are here introduced, 
but they inculcate the important practical lesson, that the disease at this 
age may be so obscure, or latent, as to be overlooked even by good diag- 
nosticians. 

Some observers, meeting cases of valvular disease in children, without 
the history of rheumatism, have concluded that rheumatism is not the 
chief cause of endocarditis at this age (Dr. A. Steffen, Jahrbuch filr 
Kmderk., 1870); but the explanation which I have given seems to me 
more in consonance with the facts. Scarlet fever not infrequently causes 
endocarditis, but this exanthem is not apt to occur without detection, and 
it has been as often absent as has rheumatism from the histories as given 
by the parents of young children with valvular disease, whom I have 
examined. Moreover, the endocarditis of scarlet fever is in many cases 
associated with, if it do not result from, scarlatinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary form 
occurs chiefly in the declining stage of scarlet fever and variola. It is 
stated, also, to occur occasionally in new-born infants during epidemics of 
puerperal fever. I have not observed such cases. 

Causes. — An inherited rheumatic diathesis is universally recognized 
as an important predisposing cause of this disease, so that it is apt to 
occur in different members of the same family. When the family his- 
tory shows a strong predisposition to rheumatism, it occurs in the child 
from a slight exciting cause ; if no such predisposition exists, it only occurs 
through unusual circumstances of exposure. The ordinary exciting cause 
is the same as in most idiopathic inflammations, namely, exposure to cold ; 
but a strong rheumatic diathesis appears to be sufficient in itself to produce 
an outbreak of the disease. Children who have had one attack are espe- 
cially liable to another. 

Symptoms The commencement of acute idiopathic rheumatism is in 

most cases sudden ; occasionally fever, and a degree of soreness or stiff- 
ness, precede the articular affection for a few hours or days. The inflam- 
mation, slight at first, increases gradually, attaining its maximum intensity 
within one or two days. The joint is painful, red, hot, and swollen. The 
swelling is due to inflammatory oedema of the tissues surrounding the joint 
and effusion within the joint. As in all inflammations, the vascularity of 
the parts involved is increased, the synovial membrane loses more or less 
its lustre, and the effused fluid, which is mainly serum, has been found, in 
most of the cases in w T hich an opportunity was presented to examine it, to 
contain, like the pleuritic exudation, a few globules of pus. Rarely, in a 
reduced state of the system, so much pus is produced within the joint as 
to constitute a true abscess, and rarely also fibrin is exuded, producing a 
rubbing sensation when the joint is moved, and endangering permanent 
adhesion of the articular surfaces. Fortunately, however, in the vast 
majority of cases, the substance exuded both without and within the joint 



328 ACUTE RHEUMATISM. 

is mainly serum, and hence the rapid subsidence of the swelling when 
the inflammation ceases. The pain is commonly not severe when the child 
is quiet, but it is greatly increased if the joint is pressed or the limb 
moved. 

The joints of the extremities are most frequently the seat of rheumatic 
inflammation, but occasionally those of the trunk, as the intervertebral, 
the symphysis pubis, etc., are involved. As the inflammation abates in 
the articulations first affected, it reappears in others, unless the materies 
morbi has been eliminated from the system. It is seldom that more than 
two or three of the joints are in a state of active inflammation at the same 
time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency 
depending on the age of the patient, as well as the gravity of the disease. 
Perspiration is a common symptom. The appetite is impaired, the tongue 
slightly coated, and the bowels constipated. The watery element in the 
urine is diminished, as in most febrile diseases. There is no corresponding 
reduction in the solid elements, so that the urine is rendered more dense, 
and its specific gravity is high. The amount of urea and coloring matter 
excreted from the kidneys is augmented during the active period of rheu- 
matism, and the urine, when it cools, deposits urates. In ordinary cases 
there is no prominent symptom referable to the nervous system, with the 
exception of pain in the affected joint. 

Acute rheumatism, if only the articulations were involved, would be a 
disease of little danger, however painful, but unfortunately, in its prone- 
ness to produce specific inflammation of the sero-fibrous tissues, the heart 
frequently becomes involved, less frequently the lungs and pleura, and in 
rare instances the cerebral or spinal meninges. Endocarditis is the most 
frequent of the heart inflammations occurring in rheumatism ; pericarditis, 
though less common, is not infrequent, while in rare instances myocarditis 
occurs, usually associated with the other inflammations. Endocarditis is 
limited to the left side of the heart, and seldom continues long without 
engaging the valves, aortic or mitral, or both, causing their infiltration, 
fibroid degeneration, with consequent thickening, and sometimes adhesion. 
The valvular lesion thus produced is in most instances permanent, so im- 
pairing the action of the valves as to obstruct in greater or less degree the 
flow of blood through the orifice or allow its regurgitation. 

The mitral valve is more frequently affected than the aortic, at least 
bruits produced by this lesion are more frequent in the mitral than aortic 
orifice, and when they are heard in both orifices they are commonly loudest 
in the mitral. This fact, noticed by different observers, I have repeatedly 
verified by observations in this city. 

While the articular affection pertains to the clinical history of rheuma- 
tism, the internal inflammation, whether of the heart, lungs, pleura, or 



DURATION — PROGNOSIS. 329 

meninges, though similar as regards its pathological character, is properly 
regarded as a complication. Acute rheumatism is so frequently compli- 
cated by one or the other of these affections, that any disproportionate 
severity in the general symptoms, as compared with the inflammation of 
the joints, or any sudden and unexpected increase in the symptoms, should 
always lead the physician to examine thoroughly the condition of those 
organs which are most frequently affected. 

Inflammatory complications occur, as a rule, during the active period 
of rheumatism, when the inflammation is passing from joint to joint. If 
the general symptoms begin to improve, and no new joints are involved, 
the liability to complications is greatly diminished. Secondary rheuma- 
tism, occurring in most instances in connection with certain eruptive 
fevers, especially scarlatina, commonly affects only a few joints, often only 
one or two, as the wrist, and, though painful, is attended by slight swell- 
ing and redness. 

Dcratiox — Prognosis With proper treatment and without compli- 
cation the febrile action in a few days begins to abate, and the disease, 
commonly terminates within two weeks. Its duration is ordinarily shorter 
than in rheumatism of the adult. Fluctuations, however, are liable to 
occur. The disease may appear to be abating, and the articular inflam- 
mations nearly cease, when they return for a time, often without new ex- 
posure and without appreciable cause. The prognosis, even when cardiac 
imflammation has supervened, is in most cases favorable, except so far as 
the lesion resulting from this inflammation is concerned, which being 
permanent may entail much subsequent suffering, and occasion death after 
months or years. Indeed, what is most to be dreaded in cases of acute 
rheumatism is valvular disease or pericardial adhesion with its remoter 
consequences, namely, hypertrophy of heart, congestion and oedema of the 
lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is sometimes also com- 
plicated with, or rather coexists with, cardiac inflammation, pleuritis, or 
pneumonitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheumatism abate, but the 
joints remain stiff and more or less swollen, and painful when moved. 
The acute has lapsed into a subacute or chronic rheumatism. Such a case, 
represented in the accompanying figure, was brought to the children's class 
in the Outdoor Department at Bellevue Hospital, in February, 1871. E. 
H., female, oj? years old, had intermittent fever from the age of nine to 
fifteen months. From this time, she remained well till the age of two 
years, when she was taken with acute rheumatism, commencing in her 
ankles and extending to other joints. The knee and hip joints on both 
sides have only partially recovered their mobility, and both legs and both 
thighs are permanently flexed, so that the gait is slow and unsteady. It 
is impossible to straighten either limb without causing great pain, and 



330 



ACUTE RHEUMATISM 



Fig. 16. 



attempts to straighten the thigh produce the arch in the back very similar 
to that in coxalgia. 

Diagnosis. — This is not difficult in ordinary cases, if a proper examina- 
tion is made. In the commencement, if the affection of the joints is slight, 
rheumatism might be mistaken for remittent, typhoid, one of the eruptive 
fevers, or meningitis ; but, on careful examination, tenderness will be ob- 
served of one or more of the articulations, and pro- 
bably some swelling. This tenderness is readily 
distinguished from the hyperesthesia which is com- 
mon in the first stage of the essential fevers, and 
which is observed when pressure is made upon the 
chest or abdomen as well as upon the limbs, and is 
more marked between the joints than in them. Any 
doubt which may at first exist, whether the patient 
may not have one of those diseases, is soon dispelled, 
since their clinical history presents notable differences 
from that of rheumatism. 

I have known scrofulous arthritis, or scrofulous 
ostitis near the joint, present so close a resemblance 
to acute rheumatism as to be at first mistaken for it. 
In one instance this inflammation commenced in 
three joints distant from each other, so that the 
diagnosis at first was difficult. But scrofulous in- 
flammation as well as that from pyaemia can be diag- 
nosticated from rheumatic disease of the joints, by 
its greater persistence, less induration and symme- 
try in the swelling, and by the history of the case. Chronic rheumatism 
may produce deformity similar to that from chronic scrofulous inflamma- 
tion, as in the case mentioned above, but the rheumatic history, number of 
joints affected, bilateral character of the inflammation, good general health, 
etc., are sufficient to establish a clear diagnosis. 

Treatment. — The theory of the pathology of a disease determines the 
mode of treatment, and the theory that rheumatism is due to an acid in 
the blood, probably lactic, though not established, has been widely received, 
and has led to the extensive employment of alkalies, as tartrate of soda 
and potassa, acetate of potassa, etc. The alkaline treatment apparently 
materially abridges the duration of acute rheumatism ; but lately a new 
remedy, namely, salicylic acid, has been found to act almost as a specific 
in a large proportion of cases, quickly relieving the pain, and subduing the 
inflammation, so that a few days suffice to effect a cure. Speedy cure of 
this malady is urgently demanded, on account of the imminent peril of 
the heart. Children seem very liable to the cardiac complication. Al- 
though salicylic acid frequently causes the disappearance of all symptoms 
within a week, they are apt to reappear unless the medicine is continued 




TREATMENT. 331 

in occasional doses for some days subsequently, as I have had opportunity 
to observe. It should be prescribed with an alkali, as in the following 
formula, which is similar to one employed in the Out-Door Department at 

Belle vue : — 

R. Acid, salicylic, 5ij 5 
Potas. acetat., ^ss ; 
GrlycerinEe, §j ; 
Aquae, q. s. ad ^v. Misce. 
Give one teaspoonful every three hours to a child of six years. 

A new remedy, producing useful therapeutic effects, is apt to be pre- 
scribed at first for too many distinct pathological states, till finally its use 
is restricted to such conditions as it is found to relieve. Salicylic acid 
has undergone this trial, and, while it has been rejected as a remedy for 
the infectious diseases, it is recognized as the most useful of all remedies 
for the disease which we are now considering. An occasional opiate, as 
Dover's powder, may also be needed between the doses of the acid. 

During the declining period of rheumatism and in convalescence quinine 
or some preparation of cinchona should be employed and the above medi- 
cine given less often. This tonic does indeed appear to exert a beneficial 
effect on the course of rheumatism, and it is employed by some judicious 
and experienced physicians from the commencement. 

If there are a high temperature and a quick pulse, quinine administered 
in an occasional large close will be found very useful. Three to five grains 
may be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins to 
present an anaemic appearance, when he requires iron in addition to the 
vegetable tonic. The citrate of iron and quinine may then be employed. 

Secondary rheumatism requires sustaining treatment from the first. 
Such cases ordinarily do well without anti-rheumatic treatment, with the 
general supporting measures employed for the primary disease. 

Pneumonitis complicating rheumatism is best treated by moderate 
counter-irritation and emollient poultices, and the internal use of carbonate 
of ammonia ; or, if there is anaemia, carbonate of ammonia with citrate of 
iron and ammonia. The other internal inflammations which are liable to 
arise as complications require iodide of potassium in decided doses. In 
pericarditis or endocarditis, if, as is commonly the case, the movements of 
the heart are accelerated, quinia in large doses, or the tincture or infusion 
of digitalis, is urgently demanded to the extent of reducing the number of 
pulsations to near the normal frequency. A child of six years can take 
three or four drops of the tincture or a large teaspoonful of the infusion, 
to be repeated, if necessary, in three hours, till the required reduction of 
the pulse is effected. Patients often experience relief, by the use of this 
agent, from the palpitation and dyspnoea consequent upon the embarrassed 
movements of the heart. If the heart disease is severe and pulse feeble, 
quinine is also useful. 



332 ERYSIPELAS. 

The patient should be kept quiet, in a room of uniform temperature, 
and not exposed to draughts of air. By such precaution the danger of 
complications is greatly diminished. Repellent applications, as cold or 
irritants, should not be applied to the joints, as long as the disease is 
acute, for they also increase the danger of complications. The affected 
joints -should be enveloped in flannel or cotton, and the pain, if intense, 
may be diminished by applying flannel wrung out of warm water. If the 
disease becomes subacute or chronic, if the urates have disappeared from 
the urine, and the inflammation ceases to pass from joint to joint, the 
tincture of iodine, or moderately stimulating embrocations, applied to the 
joints, involve no danger and are useful. 



CHAPTER VI 

ERYSIPELAS. 



The term erysipelas is applied to a constitutional or blood disease, 
which is characterized by inflammation of the skin and subcutaneous con- 
nective tissue, and by a tendency to spread. It is accompanied by 
pungent and pricking heat, swelling, and subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has been 
designated erysipelas occurs in and around the umbilicus. It commences 
about the time of the detachment of the umbilical cord, and is accom- 
panied by redness of the skin, tumefaction, and hardness of the connective 
tissue surrounding the umbilicus. It usually causes ulceration of the 
umbilical fossa, and, in fatal cases, pus is sometimes found in the umbilical 
vessels. This disease does not show any tendency to spread ; the diameter 
of the inflamed surface is not more than three or four inches, with the 
umbilicus at the centre. It is generally fatal ; but two favorable cases 
have been reported to me, in one of which there was considerable ulcera- 
tion, and after recovery a firm cicatrix occupied the site of the umbilicus. 
The most reasonable view is that this disease is primarily an inflammation 
of the umbilical fossa and vessels, induced by uncleanliness, cachexia, or 
other cause. It lacks the distinguishing feature of erysipelatous inflam- 
mations, namely, the tendency to spread, and I shall, therefore, take no 
further notice of it in this connection. (See Diseases of the Umbilicus.) 

Erysipelas seldom occurs in childhood ; the few cases which are met in 
this period present nearly the same features, and pursue nearly the same 
course, as in the adult. In infancy, on the other hand, erysipelas is a 
common disease. Every practitioner is called to cases, from time to time. 
The following remarks relate to erysipelas occurring in this period of life. 
They are based on data derived mainly from the records of cases which 
occurred in this city, some in my own practice, and others in the practice 



ERYSIPELAS. 



333 



of physicians known to be good observers. The points of chief interest in 
forty-one cases are embraced in the following table : — 

Cases of Infantile Erysipelas. 







Age. 


Point of 


6 


<D 


commencement. 


z 


w 






1 


M. 


5 months. 


Right knee. 


2 


M. 


2 years. 


Left knee. 


3 M. 


10 months. 


Elbow. 


4 F. 


20 months. 


Below right 
knee. 


5 F. 


9 months. 


Yulva. 


6 M. 


9 days. 


Genitals. 


7 


F. 


1 year. 


Vulva. 


S 


F. 


6 weeks. 


At or near the 


• 






ear. 


9 




9 months. 


Epigastric re- 
gion 


10 


F - 


10 months. 


At angle of 
month. 


11 


F. 


4 weeks. 


Vulva. 


12 F. 


3 months. 


Vulva. 


13 F. 


4 to 5 mos. 


Vulva. 


14 F. 


5 months. 


From syphilitic 
sores around 
anus. 


15 


F. 


3 months. 


Vulva. 


lb 


M. 


S months. 


Face near nos- 
trils. 


17 F. 


4 months. 


Vulva. 


18 F. 


7 months. 


Knee. 


19 F. 


6 months. 


Near the ear. 


20 


M. 


7 days. 


Left eyelid. 


21 


M. 


14 days. 


Genitals. 


22 


M. 


3 months. 


Under the chin. 


21 


F. 


2S months. 


Eight shoulder. 


24 


F. 


3 or 4 days. 


Vulva. 


2o 


F. 


3)4 mos. 


Under left ear. 


26 




7 months. 


Below right 
knee. 


27 


F. 


6_ months. 


Vulva. 


28 


M. 


19 months. 


Near point of 
vaccination. 


29 


M, 


4 months 


Near point of 
vaccination. 


30 


F - 


2 months. 


Near vaccine 
vesicle. 


31 




3 to 4 mos. 


Near vaccine 
vesicle. 


32 


F. 


4 months. 


Near vaccine 

vesicle. 


33 


M. 


2 months. 


Near vaccine 

vesicle. 


34 


M 


5% mos. 


Near point of 
vaccination. 


35 


M. 


2)4 mos. 


Near point of 
vaccination. 


36 


M. 


S months. 


Near vaccine 
vesicle. 


37 




5 months. 


Left foot. 


38 




5 weeks. 


At one ear. 


39 




2 months. 


Left leg. 


40 


' 


4 months. 


Near point of 
vaccination. 


41 


M. 


14 months. 


Face. 



Parts affected. 



Duration. Eesult. 



Entire surface, except face and scalp. 5 weeks and Recovered. 

3 days. 
From a little above the knee to the ankle. 7 days. Recovered. 

Whole arm and forearm. Recovered. 

Entire leg, thigh, and trunk to the um- 7 days. Recovered. 

Lilicus. 
Abdomen, chest, and all the extremities. IS days. Recovered. 

Both lower extiemities, abdomen to the 6 days. Lied. 

umbilicus. 
Entire surface, except face. 6 weeks. 

Forehead and side of face. 1 week. 



Trunk and lower extremities. 



Entire face and scalp. 



10 days. 



Entire surface, except face. 3 weeks. 

Surface of abd men to umbilicus and 2 weeks. 

right lower extremity. 
All \he limbs and trunk, except the 3 to 4 weeks. 

chest. 
Trunk and both lower extremities. 



Recovered. 

Lied in 
tetanic 
spasm. 

Died in 

j tetanic 
spasms. 

Recovered. 

Died. 
Recovered. 

Died. 



Entire trunk and both upper extremities. 
Entire trunk and both uppei' extiemities. 

Entire trunk and all the extremities. 

A portion of trunk and Loth lower ex- 
tremities. 

Entire face and forehead. 

Left side of face. 

Extended to knees, over abdomen to the 
chest. 

Chin, left cheek, neck, left side of trunk, 
left thigh and leg. 

Arm and forearm. 



3 weeks. 

About 2 

weeks. 

1 week. 

3 weeks. 

10 days. 

3 days. 

4 days. 



Recovered. 
Recovered. 

Died. 
Recovered. 

Recovei ed. 

Died. 

Died. 



Body and all the limbs. 
Neck, chest, and arnia. 

Trunk, neck, and head, and all the limbs. 

Both thighs, and nearly entire trunk. 

Shoulder, arm, and forearm. 

Chest, and both upper limbs. 

Trunk and all the limbs. 

Arm, forearm, and shoulder on one side. 

Arm, forearm, and trunk. 

Nearly entire surface. 

Arm and forearm. 

Arm. 

Arm and forearm. 

Leg, thigh, and lower part of trunk. 



Entire surface. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 



1 day. 

il2 days. 
About 2 
weeks. 

2 weeks. 

! 

j 3 days. 

21 days. 

2 weeks. 
10 days. 
2to3 weeks 

2 months. 

1 week. 



7 days. 

17 days. 
2 weeks. 



2 weeks 
2 weeks 
2 weeks 



Died in con- 
vulsions. 
Died. 

Died. 

Died coma- 
tose. 

.Died coma- 
tose. 

Recovered. 

Recovered. 

Died. 

Died. 

Died. 

Died with 
peritonitis. 
Recovered. 

Died, prob- 
ably of 
peritonitis. 
D.ed. 

Died with 
pneumo- 
nitis. 

Recovered 

Recovered. 

Died. 



4 weeks. Recovered. 



334 EKYSIPELAS. 

Age — Of the above cases, 27 were under the age of six months ; 9 from 
six months to twelve, and only 5 above the latter age. A large majority, 
therefore, of cases of infantile erysipelas occur in the first year of life. 

Point of Commencement In 58 cases in which I have ascertained 

the point of commencement, it was in 13 cases the vulva, 17 the arm after 
vaccination, 7 the leg, 6 the face, 3 the male genital organs, 3 at or near 
the ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the foot. In the adult, 
idiopathic erysipelas commonly commences upon the face, and affects only 
the face, ears, forehead, and scalp. On the other hand, in infantile ery- 
sipelas, statistics show that the rash commences upon the face only in a 
small proportion of cases, one in nine, and that it rarely extends to the 
face when it commences in other parts.. 

Causes — In erysipelas the first departure from the healthy state occurs 
in the blood, or the system generally. This undergoes certain changes 
which predispose to erysipelas, or are sufficient in themselves to give rise 
to it. Among the causes which produce this state of system, uncleanli- 
ness, residence in damp, dark, and crowded apartments, and defective 
alimentation, hold a principal place. Hence this disease is more common 
in the poor quarters of the city than in the country, and in dispensary and 
hospital than in civil practice. 

In a large proportion of cases there is a local exciting cause of the ery- 
sipelatous eruption, namely, an irritation or inflammation at some point, 
generally trivial, but which is sufficient to develop the disease in the sys- 
tem already prepared for it. It is very apt to commence at or near a 
simple ecthymatous or impetiginous eruption, around burns or suppurating 
sores or syphilitic eruptions ; it frequently commences, as is seen by the 
above table, near the point of vaccination immediately after vaccination, 
or when the pock is developed, or again when it has run its course and 
been detached. In a considerable proportion of cases it commences at a 
point where the skin is thin and delicate, or where it unites with a mucous 
surface, probably from some uncleanliness or irritation of those parts. 
Thus, I have records of cases in which it commenced at the external ear, 
commissure of the mouth, and at the vulva. Indeed, the frequency with 
which it commences at the vulva renders female infants more liable to it 
than males. In some instances erysipelas begins without any local ex- 
citing causes, upon smooth and sound skin, even when there are sores upon 
various parts of the surface. 

Vaccination, as an exciting cause of erysipelas, demands particular no- 
tice. Often, doubtless, it is the inflammation which necessarily arises from 
the cut or the vesicle, which operates as an exciting cause of the erysipela- 
tous affection, and not any deleterious property contained in the virus 
which is employed, so that an equal degree of inflammation occurring in 
any other way, as from a burn, would be attended by a like result. But 
facts show that the virus itself occasionally contains a latent noxious prin- 



causes. 335 

ciple, which, introduced into the system, operates as a cause of erysipelas. 
Thus, a little girl was vaccinated by me in November, 1860, and about 
the time when the vesicle began to fill she was seized with severe inflam- 
mation of the fauces, attended by tumefaction and infiltration of the sub- 
mucous connective tissue. The inflammation rapidly subsided, and within 
a week from its commencement the throat affection had nearly or quite 
disappeared. I now believe that the disease of the fauces was erysipelatous, 
although it was not suspected at the time to have this character. 

As the girl was otherwise healthy, and the vaccine vesicle passed 
through its usual stages, and presented the usual appearance, the scab was 
employed six weeks afterwards to vaccinate two infants. Within twenty- 
four hours after vaccination both these infants were seized with high fever, 
ushering in severe erysipelas, commencing in one around the point of 
vaccination, and in the other around syphilitic sores near the anus. In 
the former case the erysipelatous rash extended from the shoulder over 
the entire limb, and was obstinate, twice reappearing, and extending over 
the same surface ; in the latter (a mulatto child) it extended over both 
lower extremities and a considerable part of the trunk, when the case 
passed into the hands of another physician, and the result is not known. 
The instrument with which the vaccinations were performed was clean. 
The vaccine disease did not appear in either of these cases. 

Again, a w T ell-known physician of this city vaccinated three infants, 
one his own (No. 32 of the table), with part of a scab which had been 
pronounced good, but was taken from a child that he had not seen, and 
with whose state he was not familiar. These infants were all affected 
w T ith erysipelas from the vaccination, his own dying. He had taken the 
precaution to rub the lancet on his boot before using it. Another phy- 
sician of this city has informed me that he vaccinated two children in the 
•same family with a scab, with all the precautions that he had ever used, 
and both were soon after affected with erysipelas of a severe form, extend- 
ing from the point of vaccination ; the vaccine disease did not appear. I 
have heard of no case in which the vaccine lymph gave rise to erysipelas, 
and, probably, it rarely or never does. In the lymph there is no admixture 
of foreign substances, whereas in the scab there is a large proportion of 
animal matter. 

There is a form of erysipelas which occurs in the infant immediately 
after birth, and which is sometimes met in private practice, but is most 
frequently observed as an epidemic in lying-in wards. It is associated 
with severe, and commonly fatal, puerperal or septic fever, or erysipelas 
of the mother. This form of erysipelas is fatal, almost without exception, 
and its contagiousness is generally admitted by those, who have had an 
opportunity to observe cases. 

A case showing the relation of erysipelas in the newly-born infant to 
disease of the mother occurred in the practice of Dr. Learning, of this 



336 ERYSIPELAS. 

city. A woman gave birth to a healthy infant, on the 27th of July, 1860. 
A few days subsequently she was seized with a chill, followed by erysipe- 
las, commencing on the thighs, and terminating fatally August 17th. As 
no autopsy was allowed, the state of the internal organs was not ascer- 
tained. A few days before her death the same disease commenced on the 
infant. It extended around the neck, upon the ears, down the arms, and 
terminated fatally August 24th. But erysipelas in the new-born infant, 
occurring in connection with erysipelas in the mother, is more rare than 
its occurrence with puerperal fever. The records of lying-in asylums fur- 
nish many examples of epidemics of puerperal fever, in which the infants 
of affected mothers perish of erysipelas. 

The late Dr. Folsom, of this city, furnished me the following sketch of 
cases which occurred in his practice and that of his partner: " About the 
year 1840, being then in practice in New Bedford, Mass., I was called to 
visit a man who complained of pain in the knee. The next morning he 
was easier, but the following evening his symptoms grew worse, and as I 
was engaged in a case of obstetrics, my partner, Dr. E. C, now dead, 
visited him. At my call, next morning, I unexpectedly found the patient 
dying. The disease was obscure, and at the autopsy next day no lesion 
was discovered. In making the examination, Dr. C. pricked his finger, 
and experiencing little inconvenience from it at first, he attended a case 
of confinement on the following morning. A few hours subsequently he 
was taken sick, and I took charge of the lady, who died in three days, 
having the tumid abdomen and symptoms of childbed fever. The infant 
of the patient was seized, when two days old, with erysipelas, appearing 
on the face and in spots on the trunk and limbs, and terminating fatally in 
one day. Dr. C.'s finger became swollen and painful, and the lymphatics 
of the forearm and arm became inflamed, presenting red lines, and the 
axillary glands suppurated. Though feverish and much prostrated, there 
was no appearance of erysipelas in his case. In about two weeks he re- 
sumed practice, and as at that time physicians in this country were not 
fully aware of the danger of communicating puerperal fever, he attended 
two, three, or four obstetrical cases each week, until the number reached 
fifteen. All the mothers died with symptoms of metro-peritonitis, and all 
the infants had erysipelas, commencing on the face or some part of the 
body, generally on the second or third day after birth, and in all termi- 
nating fatally within a week. This sad record was finally ended by the 
doctor's temporarily retiring from practice." 

Dr. Condie, in his Treatise on Diseases of Children, says : " Erysipelas 
of infants very commonly occurs during the prevalence of epidemic puer- 
peral fever. Children of mothers who become affected with the fever are 
often born with erysipelatous inflammation ; others are attacked almost 
immediately after birth. Whether, in these cases, the disease is to be 
referred to a morbid matter applied to the skin in the womb, or to the same 



SYMPTOMS. 337 

epidemic or endemic influence which gives rise to the disease of the 
parent, it is difficult to say. According to M. Trousseau, infantile ery- 
sipelas is principally observed when puerperal fever prevails in the wards 
of the lying-in hospitals at Paris." In private practice it is rare that we 
meet erysipelas of the infant associated with erysipelas or with puerperal 
fever in the mother. Some of the oldest physicians of this city, with 
whom I have conversed, and who are engaged in extensive general prac- 
tice, state that they have never met a case in which there was this rela- 
tion. Cases like those observed by Drs. Folsom and Learning only occur 
when epidemic erysipelas or puerperal fever is prevailing. 

Premonitory Symptoms Infantile erysipelas in certain cases has no 

premonitory stage, or, if present, it escapes notice. In other instances 
there are well-marked precursory symptoms, as drowsiness, or restlessness, 
febrile movement, oppressed respiration, with perhaps vomiting, and start- 
ing or twitching of the limbs. In Cases 28 and 37 of the table, which 
occurred in my practice, the febrile movement, restlessness, and oppressed 
respiration were so great for three days before the appearance of the erup- 
tion, as to cause much anxiety. In the adult, pharyngitis often precedes 
the occurrence of the rash upon the skin. The same inflammation may 
be present in the premonitory period of infantile erysipelas, as well as 
during the period of erysipelatous eruption. The hurried and difficult 
respiration, which is present in the commencement of some cases, is 
probably due to an erysipelatous turgescence of the bronchial mucous 
membrane. 

Symptoms — The patient with this disease is usually restless, in conse- 
quence of the burning pain which accompanies the eruption. In severe 
cases there is little sleep, night or day, except from medicine. The sleep 
is short, and is often interrupted by sudden starting, or twitching of the 
limbs. Convulsions may occur, but are not common. 

Febrile movement is constant, and is proportionate to the extent and 
gravity of the erysipelas. I have notes of cases in which the pulse was 
more than 200 per minute, although other symptoms did not indicate im- 
mediate danger. The skin not affected by erysipelas is dry and hot, 
though not possessing the pungent heat of the inflamed portion ; face often 
flushed ; tongue moist, and covered with a light fur ; stomach usually re- 
tentive. The state of the bowels varies ; sometimes they are regular, 
sometimes variable, while in other cases the stools are green, and more 
frequent than natural. I have records relating to the state of the bowels 
in twenty cases, as follows : in seven, regular ; in nine, loose ; in two, 
constipated ; in one, constipated, then loose ; and in one, constipated, then 
regular. Diarrhoea, when present, is usually mild, requiring little or no 
treatment. The erysipelatous redness is not in all cases so pronounced as 
in the adult, but otherwise there is nothing peculiar in its appearance. In 
feeble infants, with an impoverished state of the blood, its color is pink, 
22 



338 EEYSIPELAS. 

instead of the deep red which characterizes the inflammation in the robust. 
Points of vesication may occur where the inflammation is most severe, as 
in the adult, and subsequently the same desquamation and oedema. 

If the infant is debilitated, there is great danger of the formation of 
abscesses, around which the inflammation lingers after it has disappeared 
from every other part of the body. Sometimes also, in very young infants, 
gangrene occurs, especially of the genital organs in the male. Several of 
these cases have been related to me, all under the age of a month or six 
weeks, and all fatal. Occasionally the sloughing is so great as to denude 
the testicles. A noteworthy feature of erysipelas in infants is its prone- 
ness to return. When it has been progressively subsiding, and hope is 
entertained of its speedy disappearance, it not infrequently is suddenly 
relighted from some unknown cause, travelling again over the same, or 
parts of the same, surface. In one case the disease, arising from vaccina- 
tion, extended three times over the arm and forearm ; and in another 
case, a second time over both legs and a considerable part of the trunk. 

The internal inflammations, which most frequently complicate erysipe- 
las, and give rise to symptoms which are superadded to those pertaining 
to the erysipelas, are pharyngitis and peritonitis ; and more rarely broncho- 
pneumonia or enteritis. In a case which I examined after death, in the 
Nursery and Child's Hospital, and in which, the erysipelatous inflamma- 
tion having extended over the abdomen, the lesions of peritonitis were 
present, it seemed probable, from the thinness of the abdominal walls, that 
the inflammation had extended through the parietes from the external to 
the internal surface. 

Prognosis — Erysipelas is much more fatal in infancy than in adult 
life. In the death statistics of this city for three years, I find eighty 
deaths from erysipelas of infants under the age of one year, to eighty- 
three deaths from this disease above that age. Age greatly influences the 
prognosis. Infants under the age of three weeks usually die ; from the 
age of three weeks to six months the result is doubtful; while above the 
age of six months a majority recover with correct treatment. It will be 
seen by the foregoing table that seven infants under the age of six weeks 
had erysipelas, and six died ; from the age of six weeks to six months, six 
recovered and nine died ; and above the age of six months, nine recovered 
and four died. 

"With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered, of whom I have obtained information, was 
three weeks old. In this case the rash extended nearly over the entire 
surface, beginning with the face. Case 38 of the table, treated by myself, 
was very similar as regards the extent of the erysipelatous eruption and 
the result. This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when 
it affects the limbs than when it invades the head, neck, or body; when it 



PATHOLOGICAL ANATOMY. 339 

spreads slowly than rapidly; when it is superficial than when phlegmonous. 
In those cases in which the connective tissue is much involved, the infant 
is not always safe after the disease has run its course ; he sometimes dies 
exhausted from the discharge of abscesses : I have records of two such cases. 

Duration. — In sixteen cases that recovered, the erysipelas terminated 
within the first week in two, the second week in six, the third week in five, 
fourth week in one, and in two cases it lasted five and six weeks. The 
average duration was fifteen days. In nineteen fatal cases, ten died within 
the first week, five the second week, three the third week, and one in the 
fourth week. The average duration of fatal cases was about ten days. 

Modes op Death Death occurs in different ways ; in clonic or tonic 

convulsions followed by coma, from exhaustion, and from internal inflam- 
mation, that from exhaustion being probably the most common. 

Pathological Anatomy The blood doubtless in this disease under- 
goes certain pathological alterations previously to the occurrence of the 
eruption, but the exact changes are not known. Our knowledge of the 
morbid anatomy of erysipelas relates chiefly to the local affections, which, 
with the exception of the inflammation of the skin, are not constant, and 
may, therefore, be regarded as complications. The cutaneous inflamma- 
tion affects all the structures of the skin, and in greater or less degree also 
the subcutaneous connective tissue. The inflanimation is accompanied by 
more or less serous effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with erysipelas 
has long been known. In Heberden's Epitome Morborum Puerilium, the 
anatomical character of erysipelas is expressed in one sentence : " When 
the body has been opened after death, the intestines have been found glued 
together and covered with coagulable lymph." Since Heberden's time, 
nearly all who have written on diseases of infancy and childhood have 
mentioned peritonitis as one of the most common complications. Under- 
wood says : "Upon examining several bodies after death, the contents of 
the body have frequently been found glued together and their surface cov- 
ered with inflammatory exudation, exactly similar to that of women who 
have died of puerperal fever." Similar remarks in reference to the fre- 
quency of peritonitis in this disease are made by recent writers. 

The statistics in reference to erysipelas as well as peritonitis show that 
in infants in hospital practice, and in those affected by erysipelas during 
epidemics of puerperal fever, peritonitis is a not infrequent complication. 
On the other hand, as we commonly meet cases of infantile erysipelas oc- 
curring sporadically in private practice, there are not sufficient abdominal 
distension and tenderness to indicate peritonitis. In only one of the cases 
embraced in the foregoing table was a post-mortem examination made, and 
in that there had been no peritonitis. The occurrence of pharyngitis in 
connection with erysipelas has been already mentioned. 

Enteritis has been alluded to as another complication in infants. Diar- 



340 ERYSIPELAS. 

rhcea has been stated to be a symptom in certain cases ; it has been found 
to be dependent on enteritis of a mild grade. Billard made post-mortem 
examinations of sixteen infants who died of erysipelas, and " found in 
two gastro-enteritis, in ten enteritis, in three pneumonia complicated with 
enteritis and cerebral congestion, and in one pleuro-pneumonia." 

Treatment — On this side of the Atlantic great uniformity prevails as 
regards the treatment of erysipelas. Sustaining measures are prescribed, 
and the tincture of the chloride of iron is the tonic generally preferred. 
Whatever the intensity of the febrile reaction and the stage of the disease 
if there is no intestinal complication, ferruginous or other tonics should be 
administered. The largest doses of the tincture of the chloride of iron 
given in any of the cases in the above table were in case No. 4, namely, 
ten drops every two hours, and this patient recovered in seven days from 
a pretty severe attack. Probably, however, nothing is gained by such 
large doses, and they may irritate the intestinal surface, and increase the 
liability to enteritis, which, we have seen, complicates a certain proportion 
of cases. Four drops may be given every three hours to a child from one 
to two years of age. Instead of the iron, or in addition to it, one of the 
preparations of cinchona may be prescribed. Beef-tea, and wine-whey or 
other alcoholic stimulant, are required. 

The depressing measures recommended by certain writers cannot be too 
strongly censured. One author says : " AVe should endeavor from the first 
to allay the inflammation of the skin by energetic treatment. . . . Local 
abstraction of blood, by means of one or two leeches applied at the cir- 
cumference of the primary seat of the erysipelas, should be put in force, 
provided the power of the constitution of the children permits." Such 
treatment may explain one of this author's aphorisms, namely, the erysipe- 
las of infants is a fatal disease. 

Local treatment may be employed to arrest the extension of the inflam- 
mation, but the result in most cases is not encouraging. Solid nitrate of 
silver was employed in two cases, of which I have records, aud in both 
the result was pernicious. Troublesome sores were produced, from which 
blood escaped, and in one of the cases^ at least, death was attributed by 
the parents to this treatment, rather than to the disease. 

Tincture of iodine is a better remedy for arresting the extension of ery- 
sipelas. It should be applied from the margin of the inflammation, over 
the sound skin, to the distance of about two inches. It may be ineffectual, 
but it does not produce any unfavorable result. Soothing applications, 
like rye flour, or a lotion of sugar of lead, may be made to the inflamed 
surface, as in erysipelas of the adult. I prefer, however, for local treat- 
ment, the constant application of vaseline or glycerin and water, to which 
a few drops of carbolic acid are added. 



PAET III 



SECTION I. 
DISEASES OF THE CEREBROSPINAL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than those of 
the respiratory and digestive systems. They are also less amenable to 
treatment, and are much more fatal. They largely increase the aggre- 
gate of deaths. They contrast with the diseases of the other systems in 
their greater relative frequency in infancy and childhood than in adult 
life. This is explained, as regards the brain, by the rapid development 
and active molecular change in this organ in early life, its great impressi- 
bility by the emotions, and the thinness of the covering which protects it 
from external agencies. 

Some of the most interesting of the cerebro-spinal diseases which are 
to engage our attention, are peculiar to early life, as tetanus infantum. 
The diseases of this system also contrast with other local affections in their 
greater obscurity, especially in their commencement ; for, while maladies 
of the thorax can be readily ascertained by auscultation and percussion, 
or those of the abdomen by the nature of the evacuations or the degree of 
tenderness or distension, our means of conducting examination through- 
the bony encasement of the cerebro-spinal axis are meagre and unsatisfac- 
tory. The condition of the brain and spinal cord must be determined, 
chiefly, by the study of symptoms, and not by direct examination. The 
condition of the anterior fontanelle in young infants, however, enables us 
to determine the presence or absence of active congestion of the brain. 
If there is an excess of arterial blood, it is convex. Prominence of the 
fontanelle is common in inflammatory and febrile diseases, and is a sign 
of considerable diagnostic and prognostic value. 

Within a few years, the ophthalmoscope has been employed as a means 
of diagnosis in cerebral diseases, and although the employment of this 
instrument for such purpose is but recent, enough has been elicited to 
prove its value as an aid in determining the state of the brain. Prof. H. 
D. Noyes remarks on this subject :...." The argument for making 
ophthalmoscopic examination in all cases of brain disease, becomes irre- 
sistible. Indeed, a moment's reflection would lead to this conclusion with- 



342 DISEASES OF THE CEKEBRO-SPINAL SYSTEM. 

out any considerations drawn from pathology. The optic nerve is only an 
outlying portion of the brain ; its extremity is fully exposed to view. Sit- 
uated within about two inches of the brain, it is the only nerve in the 
body which we can inspect ; it contains bloodvessels which communicate 
directly with the intracranial circulation. We thus come into relation 
with the cerebrum, by continuity of nerve-structure and also of blood- 
vessels." 

Structural changes in the optic nerve and retina have been discovered 
by means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis 
of the sinuses, apoplexy, etc. Among the lesions which have been ob- 
served by this instrument, are hyperaemia, more or less opacity and tume- 
faction of the optic nerve, engorgement of the vessels of the retina, with 
serous or sero-fibrinous exudation and ecchymotic points. In certain pro- 
tracted diseases, as chronic hydrocephalus, in which dimness or loss of 
sight occurs, the ophthalmoscope discloses a state of atrophy of the optic 
nerve. Heretofore this instrument has been chiefly employed by ocu- 
lists, but as it comes into more general use, there can be little doubt that 
it will be recognized as an important aid in the diagnosis of obscure cere- 
bral diseases. 

Still, with all possible aids to diagnosis, the obscurity which attends the 
invasion of many of the cerebro-spinal diseases must be acknowledged. 
To the hasty and careless physician, their symptoms are often deceptive. 
Careful weighing of the phenomena, and thorough and protracted exam- 
ination, are requisite in order to insure correct diagnosis and proper treat- 
ment. Some of the cerebro-spinal affections are, in reality, sequelae of 
other diseases, as, for example, spurious hydrocephalus ; and some are, 
strictly speaking, only symptoms, as convulsions ; but, on account of their 
importance, and because they require special treatment, it is proper to 
consider them as diseases per se. 

The brain presents certain peculiarities in infancy and childhood. In 
the foetus, while the other organs are well formed, the brain, especially 
its cerebral portion, is still diffluent, and at birth it has so little consis- 
tence that it must be handled carefully to prevent laceration. This soft- 
ness is due to the large proportion of water which it contains. The follow- 
ing analyses show the composition of the brain in three periods of life : — 



Albumen, 
Cerebral fats, . 
Phosphorus, 
Osmazome, salts, 
Water, 



Infant. 


Youth. 


Adult. 


. 7.00 


10.20 


9.40 


. 3.45 


5.30 


6.10 


. .80 


1.65 


1.80 


. 5.96 


8.59 


10.19 


. 82.79 


74.26 


72.51 



At birth the brain has a nearly uniform white color. The gray sub- 
stance, in which the nervous power originates, is undeveloped. The date 
of its appearance corresponds with the first exhibition of emotion or intel- 



ACEPHALUS — ANENCEPHALUS. 343 

ligence, and the decided gray color which we observe in the brain of the 
adult does not appear until the age of full mental activity. 

In the new-born the brain is large in proportion to the rest of the body, 
and its growth during infancy and childhood is rapid. Until the fifth 
year, as appears from the observations of Dr. Peacock, its weight is about 
one-seventh or one-eighth that of the entire system, the proportions vary- 
ing somewhat in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the age 
of seven years, but, according to Dr. Peacock's statistics, it continues to 
increase till the age of twenty -five or thirty, although its growth is less 
rapid after the age of seven years than previously. 

The membranous covering of the cerebro-spinal axis is scarcely less 
interesting to the pathologist than the axis itself. I shall speak in the 
following pages of the arachnoid and cavity of the arachnoid, for conve- 
nience of description, although aware of the fact that some eminent 
authorities, as Virchow and Kolliker, whose opinions in reference to the 
minute anatomy of the system always command attention, if not assent, 
believe that there is no arachnoid, but what has heretofore been called by 
this name is on the one side the smooth surface of the dura mater and on 
the other of the pia mater. 

The dura mater is seldom involved in the diseases of early life, except 
as it is affected by pressure, while the pia mater and arachnoid are the 
seat and source of some of the most important diseases, as meningitis, 
meningeal apoplexy, etc. 

The more complicated and delicate the structure of an organ, the more 
liable it is to errors of nutrition and growth. There is, therefore, no organ 
which is so liable to irregular development as the brain. It may be en- 
tirely wanting ; or it may be partially developed, certain portions being 
absent; or, lastly, its growth may be excessive, constituting an hyper- 
trophy. 



CHAPTER I. 

ACEPHALUS— ANENCEPHALUS. 

Entire absence of the encephalon is not common, but there are many 
cases of this monstrosity on record. In extreme cases the head and part 
of the neck, as well as the brain and medulla oblongata, are absent. 
When there is great deficiency there is often a twin, the presence of which 
has interfered with the full development of the system. Sometimes the 
growth of other organs besides the brain is imperfect. 



344 



ACE PH ALUS — ANENCEPHALUS. 



Fig. I 1 ; 



Anatomical Character — In the -ordinary form of anencephalus the 
brain and sometimes the medulla are absent, with the absence or imper- 
fect development of their membranous and osseous covering. The vault 
of the cranium is absent. There is deficiency of the frontal, parietal, 
and occipital bones, except those portions which are near the base of the 
cranium. These portions are very thick and closely united, as if there 
were the usual amount of osseous substance, but instead of expanding 
into the arch, it had collected in an irregular mass at the base of the 
cranium. 

The absence of the brain and the cranial arch gives a remarkable ap- 
pearance. The eyes are prominent, the neck thick and short, while the 

body and limbs are ordinarily well de- 
veloped. The physiognomy has been 
compared to that of some of the lower 
animals. 

The base of the cranium is often oc- 
cupied by a vascular tumor, not large, 
but of different size in different cases, 
and continuous below with the spinal 
pia mater. This vascular tumor is the 
representative of the cranial pia mater, 
and its smooth surface is the analogue 
of the arachnoid. The dura mater and 
the scalp being absent, the exposed mass resembles very much in appear- 
ance, as it does in structure, the placenta, and the sensation which it 
imparts to the finger pressed upon it is very similar. Sometimes small 
portions of cerebral matter are found among the vessels of this tumor, 
but they are so disconnected or isolated that they do not perform, in any 
way, the function of a brain. Occasionally the vascular tumor is absent, 
and the medulla or upper extremity of the spine is exposed, or it termi- 
nates in a little papilla at the back of the neck. 

Those portions of the cranial nerves which lie external to the cranium 
are well developed, although the intracranial parts may be absent.' 

Symptoms The respiration in anencephalous monsters is irregular. 

They can be made to cry, but their cry is a sort of sob or hiccough, and 
occasionally they even nurse. The digestive function is well performed, 
and regular urinary and fecal evacuations occur. There is a tendency in 
anencephalous monsters to convulsions. Blowing upon them, and pressure 
upon the projecting medulla, if this is present, frequently produce this 
effect. 

Prognosis Fortunately these monsters are short-lived. If the medulla 

oblongata, which is essential to the maintenance of respiration, is absent, 
extra-uterine life is impossible. Stillbirth is the result. If the medulla 




IMPERFECT BRAIN. 345 

oblongata is present, although respiration and circulation are established, 
death commonly takes place within two or three days, and almost always 
within the first week. Convulsions sooner or later occur, ending in fatal 
coma. 



CHAPTER II. 

IMPERFECT BRAIN. 



Between the absent and complete brain there are various grades of de- 
ficiency. Parts of the brain may be perfect, while other portions are either 
absent or imperfectly formed. The deficiency is usually in the superior 
parts of the brain, especially in the hemispheres of the cerebrum, while 
the base of the organ is perfect. Both hemispheres may be absent, or one 
may be absent, while the other hemisphere is shrivelled or rudimentary. 
Occasionally the cranium preserves its normal shape and size, in conse- 
quence of an increase in the cerebro-spinal fluid proportionate to the lack 
of brain-substance. The imperfect development is not then apparent to 
the observer. The rudimentary hemispheres in these cases are spread out, 
forming the walls of a sac inclosing the liquid. The post-mortem exami- 
nation of the following case was made in the Nursery and Child's Hospi- 
tal, of this city, in 1862. 

Case — Female ; parentage healthy; she was plump and well formed at 
birth, and nothing unusual was observed in her condition, as she nursed 
and throve like other children, till she reached the age when there is, 
usually, the first manifestation of intelligence. With her there was no 
evidence of an intellect, or, if any, it was very indistinct. She nursed, or 
took food when placed in her mouth, but apparently without relish, as if 
instinctively. She never reached her hands towards the nurse, or towards 
playthings. So indifferent and apparently unconscious was she of objects 
around her, that it was thought for some time that she was blind. She 
never smiled, except when her hands were gently rubbed or shaken ; and 
then the smile seemed to be a movement more reflex than emotional. The 
smile was immediately succeeded by a fixed vacant look. She usually lay 
quietly, with her arms crossed ; and during the last months of her life she 
sometimes uttered a scream, like children with cerebral diseases. Her 
evacuations were regular, and she was not subject to vomiting, before she 
was attacked with the acute disease of which she died. The size of her 
head was rather less than usual at her age, but not less than is often seen 
in well-formed children. The forehead was small in proportion to the rest 
of the head, but the difference was not such as to attract attention. For- 
tunately, the existence of this idiot was terminated by an attack of entero- 
colitis at the age of about ten months. 

Sectio Cadav The head was measured, but the measurements were 

lost. They did not seem to differ materially from the normal standard. 
The sutures were united, and the fontanelles nearly, if not quite, closed. 



346 IMPERFECT BRAIN. 

The frontal bone lay a little lower than the plane of the parietal. The 
meninges of the brain presented nearly their normal appearance, but were 
distended with transparent serum. The quantity of fluid was estimated 
at about two-thirds of a pint, and when it was evacuated, the floor of the 
lateral ventricles was brought into view. There was almost an entire ab- 
sence of that part of the brain which lies above the floor of the ventricles. 
On close inspection, rudimentary cerebral hemispheres were found in a 
thin layer forming a part of the walls of the sac. The whole amount of 
brain-substance above the ventricle did not exceed the size of a small egg. 
The cerebellum, the base of the brain, and cranial nerves presented their 
usual appearance. The entire brain, after being a few days in diluted 
alcohol, weighed six and a quarter ounces. 

In this case, the fluid was only sufficient to compensate for the deficiency 
of the brain. In other, and probably the larger number of cases of in- 
complete brain, the cerebro-spinal fluid is not materially increased. There 
is then but slight elevation of the frontal bone, the forehead is low, or re- 
treating, or even almost absent. This is that shape of head which is uni- 
versally regarded as characteristic of idiocy. 

Symptoms The symptoms in cases of deficient brain relate to the 

mind. If the cerebral hemispheres are absent, there is no intelligence. 
The individual, as regards mental endowments, does not arise above the 
instincts of the lower animals. If the hemispheres are partially developed, 
there is a degree of intelligence proportionate to the amount of cerebral 
substance present. If the deficiency is confined to one side, there is no 
apparent lack of intelligence or mental capacity, since, the brain being a 
double organ, one side performs the function of both. 

Prognosis The prognosis as regards life, in cases of imperfect brain, 

depends not so much on the amount of deficiency as the exact seat of ar- 
rested growth. If only the cerebrum is partially, or even entirely absent, 
the infant may live and thrive. But if those portions lying at the base of 
the brain, which control the functions of animal life, are lacking, or are 
imperfectly formed, life is very uncertain, and probably short. 

It is evident that no therapeutic treatment can remedy a congenital de- 
ficiency. The services of the physician are not required. The philan- 
thropic and patient teacher may impart a degree of intelligence to the 
idiotic, and the instruction of these unfortunates has of late years been 
very successful. 

Microcephalia — Atrophy of Brain. 

An abnormally small brain has usually been attributed to premature 
closure of the sutures and fontanelles by too rapid ossification. But in 
certain cases which I have met, there was no evidence of exaggerated os- 
sification, and the fault seemed to me to be a difficiency in the growth of 
the brain, while the ossifying process was not exaggerated or was even 
less than normal. A normal development of the cranial bones, with but 



MICKOCEPHALUS — ATROPHY OF BRAIN. 347 

little brain-substance to keep them apart, would necessitate early oblitera- 
tion of sutures and fontanelles. Thus in August, 1878, an infant was 
brought into the Bureau for the Eelief of the Out-door Poor, with marked 
microcephalism. Its age was 19 months, and the bone formation was so 
slow that only two teeth had appeared ; the circumference of its head 
was 14^- inches; it had had repeated convulsions since the age of five 
months, and the mother stated that its head had been round and hard from 
its birth. In microcephalus, death, sooner or later, is the common re- 
sult ; life ends in convulsions and coma. 

Again, the brain of the child, when undergoing development, with the 
cranial bones sufficiently yielding, may not only cease to grow, but may 
even diminish in size, in consequence of protracted and exhausting diseases. 
Diminution in the size of the brain occurs especially after fevers and diar- 
rhceal affections of long standing and attended with much emaciation. 
The waste of the brain corresponds with the general loss of flesh. If the 
cranial sutures are not united, the occipital and sometimes the frontal 
bones are depressed, according to the diminished size of the brain, and are 
overlaid by the parietal. In foundlings of two or three months, this loss 
of brain-substance is often very striking. In infants of this class who have 
died of protracted diarrhoea, it is not unusual to observe the occipital bone 
not only depressed, but extending one, two, or even three lines underneath 
the parietal. 

If the child with shrunken brain, from protracted and exhaustive dis- 
ease, is old enough to express its thoughts, it often seems foolish, talks but 
little, and perhaps says the same thing over and over again. In one case 
in my practice, a little girl, having passed through a long course of typhus, 
persistently repeated during her convalescence, with a silly smile, the ques- 
tions addressed to her. This peculiarity continued two or three weeks, 
although her appetite was good, and her restoration to health rapid. In 
another case a little boy, during convalescence, was wont to laugh heartily 
at the appearance of the ordinary articles of furniture in the room. Both 
showed more impairment of mind during convalescence than in the midst 
of the fever. The friends of such children are in a state of great anxiety 
lest their minds are permanently enfeebled, but, as the appetite and strength 
return, the nutrition of the brain is re-established, and the mind regains 
its former vigor. In cases of wasted brain, with cranial bones united, the 
deficiency is supplied by serous effusion, which is gradually absorbed as 
the health of the patient is re-established, and the brain enlarges. This 
effusion occurs not only over the convexity of the brain, but also at its 
base, and sometimes in the ventricles. Dr. West states that in atrophy of 
the brain, from protracted disease, its texture is firmer than usual. I have 
not noticed this in infants, but my attention has not been directed particu- 
larly to this point. It is probable that there is some change in the ana- 
tomical character of the brain, aside from mere waste. 



348 HYPERTROPHY OF BRAIN. 

Partial atrophy of the brain sometimes, also, occurs from primary dis- 
ease located in this organ ; the affected portion wastes, while the rest 
retains its normal development. 



CHAPTER III. 

HYPERTROPHY OF BRAIN. 

In contrast with atrophy of the brain is the opposite state, or hyper- 
trophy. The size of this organ within the limits of health varies greatly 
in different individuals, but sometimes there is so great an increase in vol- 
ume as properly to constitute a disease. 

Pathological Anatomy. — The excess of growth which characterizes 
this disease has been ascertained to be confined to the white portion of the 
brain, and ordinarily to that part contained in the cerebral hemispheres. 
Hypertrophy of the brain is attended by induration, which exists in differ- 
ent degrees in different cases. It is in some so slight as to be scarcely 
appreciable ; while in others it is apparent at once by pressure with the 
finger, or incision with the scalpel. Rilliet and Barthez state that the in- 
duration in some cases resembles in degree and appearance that produced 
by the action of alcohol. The white substance of the cerebrum is not 
only resisting and elastic, but its color is unusually pale ; it presents even 
a brilliant or polished appearance. At the same time the gray substance 
is more or less faded, and its depth in the convolutions is less than in the 
normal state of the organ. Eokitansky says : " The cineritious matter is 
generally of a pale grayish-red color. The medullary is always dazzling 
white, and remarkably pale and anaemic." An unusual case is related by 
Burnet, in which the gray substance in the corpora striata retained its 
usual color, and was indurated like the white substance. In exceptional in- 
stances the cerebellum as well as cerebrum undergoes hypertrophy, becom- 
ing at the same time more or less indurated. In Burnet's case there was 
induration of the optic nerves. " The internal structure," he says, " of the 
optic nerves, especially in their bulbs, had the polish, homogeneous appear- 
ance, elasticity, and almost the hardness of cartilage." Rilliet and Bar- 
thez state that in two cases the spinal cord presented even more marked 
induration than the encephalon. Congestion is not a feature of hypertro- 
phy. On the other hand, there is often less vascularity of the brain and 
its membranes than in the healthy state. If the cranial bones are com- 
pletely ossified at the time when hypertrophy commences, and firmly 
united, enlargement of the brain is partially prevented. The convolu- 
tions are then thin, much flattened, the sulci more or less effaced, the 



CAUSES. 349 

membranes pale and dry, and the ventricles are small and nearly desti- 
tute of serum. At the autopsy of such a case, when the dura mater is in- 
cised, the expansion of the brain prevents the proper refitting of the skull- 
cap. Occasionally hypertrophy causes more or less absorption of the 
cranium, and perhaps the sutures already united are pressed apart. 

If hypertrophy commences in young infants with the fontanelles and 
sutures still open, they usually remain open, or are a long time in uniting. 
The interspaces continue, not only in consequence of the growth of the 
brain, which tends to separate the bones, but also in consequence of feeble 
ossification. The shape of the head arrests attention. Hypertrophy usu- 
allv produces most enlargement between and above the ears, while the 
frontal portion of the head, though somewhat enlarged, is less developed. 

The direction of the eyes is not changed, as is common in congenital 
hydrocephalus. 

Rokitansky says (vol. iii, page 285) : " With regard to the question to 
be decided by the theory and microscopic examination, as to the nature of 
the added material upon which the increase of volume depends, I have 
formed the following opinion from repeated investigations : — 

" 1. The disease is genuine hypertrophy. 

" 2. It consists, as such, not in an increase in the number of nerve-tubes 
in the brain, from new ones being formed, nor in an increase in the dimen- 
sions of those which already exist, either as thickening of their sheaths, or 
as augmentation of their contents, by either of which the nerve-tubes 
would become more bulky ; but, 

" 3. It is an excessive accumulation of the intervening and connecting 
nucleated substance." 

It is now generally admitted that the views of Rokitansky are correct ; 
that hypertrophy of the brain is due to an augmentation in the amount of 
connective tissue, which lies between and unites the tubules. 

Causes. — Hypertrophy of the brain results from an error in the nutri- 
tive process which sometimes seems to be associated with the rachitic 
state, oi a condition analogous to rachitis. It is not common, is indeed 
rare, in this country, and is more common in countries like England, 
where rachitis is more prevalent than with us. Rilliet and Barthez con- 
sider frequent congestions of the brain as a common cause. The hyper- 
trophy is most frequently met in hospitals for children, and among the 
poor of the cities, whose systems are rendered cachectic by residence in 
damp and dark localities, and by unwholesome diet. In the deep valleys 
of Switzerland, and in parts of South America and Asia, hypertrophy of 
the brain is common, under the name cretinism. It is associated with 
rachitis and stunted growth. The abnormal development which occurs 
in cretinism begins in infancy or early childhood, and the unfortunate 
subjects of it are short-lived. Cretinism has been attributed to a residence 
in localities wet and deprived in great measure of solar light, and to 



350 HYPERTROPHY OF BRAIN. 

general disregard of the laws of health on the part of those affected as 
well as their parents. 

The observations of different physicians also establish a connection be- 
tween some cases of hypertrophy and the saturation of the system by lead. 
In what way lead-poisoning leads to hypertrophy is obscure, but the con- 
current testimony of different observers is so strong, that we cannot doubt 
that it does sometimes have that effect. But in a considerable proportion 
of cases, as in the two presently to be related, the cause is obscure. 

Symptoms — The symptoms, as is the case with most organic diseases of 
the brain, vary considerably in different cases. Sometimes there is, at first, 
more or less depression or languor. If the child is old enough to speak, he 
may complain of pain in the abdomen or limbs, evidently neuralgic, or of 
headache. After a variable time vomiting succeeds, and finally convul-' 
sions, affecting the muscles of the face, as well as extremities ; the convul- 
sions are usually clonic, but sometimes, as regards at least the extremities, 
of a tonic character. The pupils may be contracted or dilated ; there is 
restlessness alternating with drowsiness, and finally coma succeeds. 

Hypertrophy may continue a considerable time before serious symptoms 
arise ; but when once developed, these symptoms ordinarily continue with 
more or less severity till death. Death commonly results within a week 
after their commencement, but sometimes not till several Weeks have 
elapsed. When death occurs at an early period in the disease, there is 
usually firm ossification and union of the cranial bones, and, therefore, but 
moderate enlargement of the cranium. 

If hypertrophy commences at a period not far removed from birth, the 
bones, of course, yield more readily to the pressure, and acute symptoms 
do not occur so soon. After a time, however, in all or nearly all cases, 
convulsions supervene. These indicate the gravity of the disease, and are 
prognostic of its fatal termination. 

In a patient observed by Burnet, violent convulsions, followed by loss 
of consciousness, marked the commencement of acute symptoms. Five 
days subsequently, the following symptoms were recorded : mobility of the 
eyes, without expression ; pupils contracted, and directed upwards ; di- 
vergent strabismus of the left eye ; the senses in their normal state, with 
the exception of sight ; the limbs move by volition. For a month there 
was little change. Then occurred drowsiness, and increased prostration, 
and five weeks later the child succumbed with the symptoms of double 
pneumonia. 

Such is the clinical history of hypertrophy. In cases of firm ossification 
of the cranial bones, and therefore, no marked enlargement of the skull, 
the symptoms are similar to those which occur if the dimensions of the 
head are increased, only compression and death result sooner. 

The following case, in which the sutures were firmly united, I attended 



SYMPTOMS. 351 

in 1864. The head was large, but not so large as to attract attention from 
its disproportion : — 

Case A boy, aged two years and two months, had, when about one 

year old, intermittent fever, and since then his countenance was uniformly 
pallid, and his flesh soft. Weaned at the usual time, he remained well till 
the 1st of January, 1864. In the beginning of this month he was ob- 
served to be feverish for some days, and his appetite poor. His health 
then gradually improved, and he was thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, gen- 
eral at first, but most severe and continuing longest on the left side. The 
convulsions lasted a little more than three hours. He recovered fully his 
consciousness by the following day, but his appetite remained poor ; he 
was no longer amused by his playthings, and was very fretful. The sur- 
face was pallid ; bowels constipated ; pulse but little, perhaps not at all, 
accelerated. He continued in this state till the 6th of March, when he 
had another slight convulsive attack, and from this time he never fully re- 
covered his consciousness. He was fretful if disturbed, his face generally 
pallid, while the pulse and respiration were not perceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger than 
the right, but both were sensitive to light. The difference in size con- 
tinued till near the close of life. Although vision was imperfect, if not 
altogether lost, the sense of hearing was not impaired. 

When questioned, he uniformly answered, " No," with a drawling 
voice, evidently not understanding what he said. 

As the disease advanced, the respiration became at times sighing ; but 
the rhythm of the pulse was not materially altered. The temperature of 
the surface was changeable, sometimes cool, sometimes warm, and the 
congested spots or patches, so common in cerebral affections, were also 
observed at times on the face, ears, or forehead. Through most of his 
sickness he took drinks readily, and the urine was freely discharged, pro- 
bably from the iodide of potassium, which he took in one and a half grain 
doses every two hours. 

He became more and more drowsy, again had slight convulsive move- 
ments, and finally died, with much apparent suffering, on the 14th of 
March. The pulse became more accelerated during the last two or three 
days. On the day preceding his death, the pupils were contracted, and 
not affected by the light. 

Sectio Cadav — Body somewhat emaciated, and eyes sunken ; occipito- 
frontal circumference of head nineteen and a half inches ; distance from 
one auditory meatus to the other over the vertex, thirteen and a half 
inches ; convolutions over the surface of the brain much flattened and 
compressed; brain generally deficient in blood; medullary substance firm, 
and of a pure white color ; meninges healthy; no other abnormal appear- 
ances were observed ; weight of brain forty-two ounces. 

In the following interesting case, the diagnosis was for months doubtful, 
though it was evident that the disease had a cerebral origin : — 

Harry R. L., of healthy parentage, was well till the summer of 1876, 
when he was nearly at the close of his third year. At this time he was 
observed to be feverish and fretful, and his features were flushed at times. 
He also complained almost daily of pain in the top of his head, which pain 
was intermittent, and these attacks of headache occurred for at least six 



352 HYPERTROPHY OF BRAIN. 

months, perhaps longer. There had been no backwardness in dentition, 
and no symptoms of rachitis or struma, and his nutrition was good, even 
after the commencement of the present malady. 

In February or March, 1877, his stomach became irritable, so that he 
vomited often during the following months, and about the same time he 
began to lose the use of all his limbs — a progressive paralysis — and his 
bowels became constipated. Both urination and defecation were slug- 
gishly performed. 

In July, 1877, he ceased to walk, and he has not been able. to stand 
since. 

On March 29th, 1878, the following records were made : No improve- 
ment, but a gradual increase of most of the symptoms ; lies constantly, 
and produces but little movement of his limbs, though sensation seems 
to remain in them ; his eyes are clear, and pupils moderately dilated, but 
without vision ; how long his sight is lost is not known ; axis of eyes not 
depressed, or otherwise changed, and parallelism is retained ; the cranium, 
which, during the first year of his sickness, un- 
derwent little change, has expanded rapidly dur- 
ing the last six months ; the enlargement is most 
marked above the ears ; the occipitofrontal cir- 
cumference is represented in the accompanying 
diagram : this circumference measures 21-i- inches, 
of which 9 J are in front of the ears, and 11^ 
inches posterior to the ears ; distance over ver- 
tex from one auditory meatus to the other 15^ 
inches. The anterior fontanelle is observed to 
be open, though small, the diameter being about 
one-fourth or one-third of an inch : it is not elevated, and the surrounding 
edge of bone is flexible. 

From the clinical history, the shape of the head and the unchanged 
axis of the eyes, it is believed that the above is a case of overgrowth of 
the brain, rather than of chronic hydrocephalus. 

Diagnosis The diagnosis of hypertrophy is not always easy. The 

symptoms are, in the main, such as occur in other pathological states, 
especially congenital hydrocephalus. There is most danger of mistaking 
the overgrowth for this disease. Hypertrophy has, indeed, often been 
treated for hydrocephalus. There are, however, certain signs by which 
we may distinguish one from the other. In the ordinary form of con- 
genital hydrocephalus, even when the amount of liquid is small, the orbital 
plates of the frontal bones are pressed in such a way that the axis of the 
eyes is changed so as to have a downward direction. The white of the 
eye can be seen between the iris and the upper eyelid. This gives a char- 
acteristic and striking expression to the face. The exception to this is in 
those rare cases in which the liquid is external to the brain. In hyper- 
trophy this peculiar change in the axis of the eyes does not occur. More- 
over, in hypertrophy there is not that uniform expansion of the head 
which is observed in hydrocephalus, as has been stated above. There 
are, commonly, greater enlargement, more prominence of the anterior fon- 




PROGNOSIS — TREATMENT. 353 

tanelle, and wider separation of the cranial bones, in hydrocephalus than 
in hypertrophy. 

Hypertrophy with consolidation of the cranial bones, and, therefore, 
little enlargement of the head, may be mistaken for meningitis. The his- 
tory of the case, and the means by which we diagnosticate the latter affec- 
tion, which will be described in their proper place, will usually enable the 
physician to make a correct diagnosis. 

Prognosis In forming an opinion as to the probable termination of 

the disease, we must have regard to the age and general condition of the 
child, as well as to the degree of hypertrophy. If the disease commences 
at an early age, when the cranial bones are not firmly united, it is probable 
that there will be no compression of the brain, so as to endanger life, for 
a considerable period. We may then hope by proper measures to remove 
the constitutional state which gives rise to the hypertrophy, before the 
enlargement is such as to cause cerebral symptoms. If the lonis have 
already united when the disease commences, even slight hypertrophy will 
produce symptoms, and a speedily fatal result is inevitable. Evidently, 
also, a child in a marked degree rachitic or scrofulous is much less likely 
to recover than one whose general health and constitution are less im- 
paired. 

Treatment — The treatment in hypertrophy should be directed mainly 
to the constitution. Measures calculated to improve the nutritive process 
are those most likely to check the abnormal growth of the brain. As the 
disease is one of perverted nutrition, and usually coexists with a vitiated 
or impoverished state of the blood, tonic and alterative remedies are re- 
quired. The syrupi ferri iodidi is, therefore, useful, as it is both tonic and 
alterative. This may be given in doses of three or four drops to a child 
one year old, three times daily. Cod-liver oil, with or without the iron, 
is beneficial in some cases. Another remedy is iodide of potassium in 
combination with a tonic, as the compound tincture of bark. 

R. Pot as. iodid., 5j '■> 

Tinct. cinchon. comp., 
Syr. limon., aa ^ij. Misce. 
One teaspoonful, three times daily, to a child of three years. 

The hygienic treatment is not less important than the medicinal. There 
is little hope of a favorable issue in any case, unless the regimen is such 
as will conduce to a more robust and healthy state of system. The diet 
should be plain and nutritious, the apartments clean and airy, and all 
undue excitement should be avoided. 



23 



354 THROMBOSIS IN THE CRANIAL SINUSES, 



CHAPTER IV. 

THROMBOSIS IN THE CRANIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is designated 
thrombosis (thrombus, clot). Coagulation of fibrin in the cranial sinuses 
occasionally occurs, constituting a very serious pathological state. This 
may result from local disease in the sinuses or in their vicinity, or from 
disease external to the cranium. The immediate cause of thrombosis, 
whatever its location, is sufficient arrest of the circulation to allow the 
fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or less the 
venae innominate, or the descending vena cava, sometimes give rise to 
thrombosis in the cranial sinuses, the fibrin coagulating in consequence of 
retardation in the current of blood. I have known thrombosis, in the 
same situation, also to result from clonic convulsions, occurring in connec- 
tion with severe spasmodic cough in pertussis, since both the cough and 
convulsions retard the flow of blood in the veins and sinuses within the 
cranium. At the post-mortem examination of at least four such cases I 
found whitish clots in the lateral sinuses. 

Thrombosis, in the cranial sinuses, may also occur from inflammation, 
either in the walls of the sinuses or immediately exterior to them. This 
is the disease which writers have designated phlebitis of the cranial 
sinuses, and for a correct understanding of the morbid anatomy of which 
the profession are indebted to Virchow. 

Anatomical Characters. — If a child die with the cranial sinuses 
and the veins of the brain and of the meninges in their normal state, the 
blood in these vessels is found at the autopsy dark but liquid, or there are 
small, dark, and soft clots in the larger sinuses. If there were congestion, 
but no coagulation, in these vessels in the last hours of life, the clots are 
more numerous, larger, and longer, sometimes extending from the sinuses 
into the larger veins which empty into them, but they are still dark and 
soft, readily falling to pieces when handled. If, again, there have been 
that degree of congestion and stasis which has resulted in ante-mortem 
coagulation, or in thrombosis, the clots are, in part at least, whitish, and 
of a fibrinous or gelatinous appearance ; they were formed while the red 
corpuscles were still carried along in the circulation. 

Most of the clots in thrombosis are free, while others are attached 
lightly to the internal surface of the sinus ; occasionally they are so large 



ANATOMICAL CHARACTERS. 355 

as to distend the vessel. They extend also in many cases into the cerebral 
veins which connect with the sinuses, producing prominence and firmness, 
so as to resemble (Rilliet and Barthez) an artificial injection. The clots 
do not present a uniform character. In parts of a sinus they consist of 
almost pure fibrin, of a yellowish-white color, while in other portions they 
present a gelatinous appearance from the large number of white corpus- 
cles, while other portions are more or less tinged from the presence of red 
corpuscles. The central part of the clot, after a time, if the case is suf- 
ficiently protracted, softens, and presents a puriform appearance. This 
substance, which is only disintegrated fibrin, was supposed to be pus, till 
the microscope revealed its true character. It is obvious that small clots 
forming within a sinus, and having no attachment to its walls, are liable 
to be carried by the current of blood into the general circulation, unless 
there is complete obstruction. Virchow has also shown how a thrombus 
may extend, by gradual prolongation, nearer and nearer the heart, so that 
one commencing in a sinus may, after a time, reach into the jugular vein. 
Different observers, as M. Tonnele, and also Rilliet and Barthez, have 
traced the fibrinous masses as far as the cava. The latter writers relate 
the case of a girl, four and a half years old, in whom the sinuses on the 
left side, especially those nearest the petrous portion of the temporal bone, 
were completely filled with clots of a yellowish-white color, intermixed 
with central dark spots. Similar coagula were also found in the left 
jugular vein as far as the brachio-cephalic trunk. Whether the walls of 
the sinus undergo any change depends on the nature of the disease which 
causes the thrombosis. If it be phlebitis, the coats are thickened from 
infiltration and injected, and the internal coat has lost its polish. If it 
be some obstructive disease in the course of the circulation, or a general 
cause, the coats of the vessel are unaltered, except that they may be 
stained by imbibition of the coloring matter of the blood. In an infant 
who died of this disease in the practice of Dr. West, " the sinuses on the 
left side were healthy, but the blood was almost entirely coagulated. The 
posterior half of the longitudinal sinus, the torcular, the left lateral, and 
the left occipital sinuses, were blocked up with fibrinous coagulum, pre- 
cisely such as one sees in inflamed veins, and the clot extended into the 
internal jugular vein. The coats of the longitudinal, and of the inner 
half of the lateral sinus, were much thickened, and their lining membrane 
had lost its polish, was uneven, and presented a dirty appearance." 

The mode in which congestion and coagulation occur within a sinus, in 
consequence of the pressure of a tumor upon this vessel, or upon a vein 
into which the blood from this sinus flows, is sufficiently obvious. The 
mode of the production of thrombosis, as a result of clonic convulsions, or 
of the spasmodic cough of pertussis, is also apparent. How it results 
from inflammation of the walls of a sinus, that is, from phlebitis, was not 
understood till explained by Virchow. 



356 THROMBOSIS IN THE CRANIAL SINUSES. 

The fibrinous coagula which fill the sinus are not an exudative product, 
as was formerly supposed. Inflammation (in most cases otitis, with caries 
of the petrous portion of the temporal bone) approaches a sinus. The 
inflammatory products pressing against the walls of the sinus diminish 
its calibre at that point, and hence the retardation of the current of blood 
and the coagulation. Or the walls of the sinus may be thickened by in- 
flammatory infiltration, or even by the formation of little abscesses within 
the coats in consequence of the inflammation, so as to produce bulging 
inwards, and the result, as regards the circulation, is the same. Whether, 
therefore, the inflammation occur without a sinus, or within its walls, 
thrombosis equally results, provided that the diameter of the vessel is 
sufficiently narrowed by the presence and pressure of inflammatory products. 

There is no exudation on the internal surface of a sinus or vein when in- 
flamed, as there is upon serous surfaces. " On the contrary" ( Cellular Path- 
ology, translation, p. 236), " when the wall is inflamed, the exuded matter 
(exsudatmasse) passes into the wall, which becomes thicker, cloudy, and 
subsequently begins to suppurate. Nay, even abscesses may form which 
cause the wall to bulge on both sides like a variolous pustule, without any 
coagulation of the blood ensuing in the cavity of the vessel. At other 
times, certainly, phlebitis, properly so called (and in like manner arteritis 
and endocarditis), is the cause of thrombosis, in consequence of the forma- 
tion of inequalities, elevations, depressions, and even ulcerations upon the 
inner wall which favor the production of the thrombus. Still, whenever 
phlebitis, in the usual sense of the word, takes place, the alteration in the 
coat of the vessel is almost always a secondary one, and, indeed, occurs at 
a comparatively late period." 

This view of the pathology of thrombosis comports with facts observed 
at autopsies, and which cannot be explained according to the old theory 
of phlebitis, namely, smoothness of the internal surface of the sinus ; 
natural color of this sinus, or simple staining from blood ; the non-attach- 
ment or slight attachment of the coagula, etc. 

Causes. — Some of these have been already stated at the commencement 
of this article. It is evident from what has been said that this disease may 
be produced by any cause which obstructs the return circulation from the 
head. I have already alluded to tumors which press upon the sinus, or 
on the vein below the sinus, as a cause. Among the causes may be men- 
tioned also abdominal tumors, narrowing of the chest from, rachitis, or 
caries of the vertebras, and, finally, compression of the jugular vein by a 
retropharyngeal abscess. 

Sufficient allusion has already been made to inflammation of the internal 
ear as a not infrequent cause. Thrombosis is, indeed, one of the dangerous 
results of chronic otitis. Another cause is a reduced or cachectic state of 
system, apart from any local or obstructive disease. It is a noteworthy fact 
that a large proportion of those affected with thrombosis, even when it is 



SYMPTOMS. 357 

immediately due to obstructive disease, are cachectic. The explanation of 
this fact is not difficult. In reduced states of the system the action of the 
heart is feeble, and passive congestion of the vessels within the cranium is 
apt to occur. Passive congestion of the veins and sinuses in protracted 
diarrhceal maladies, which is described in our remarks upon another dis- 
ease, is an example in point. In this state of feeble circulation very slight 
obstructive disease may be sufficient to cause thrombosis. 

Symptoms The symptoms of this disease are often obscure. All of 

them may and do occur in other maladies of the encephalon. In cases re- 
lated by M. Tonnele, cerebral symptoms were well marked, such as faint- 
ness, dilation of the pupils, strabismus, grinding the teeth, convulsive move- 
ments. There may be an almost total absence of such symptoms as would 
direct attention to the state of the head. This is due to the sudden occur- 
rence of death after the clots have formed in the sinuses. If the clots are 
large, death soon results in consequence of congestion of the brain and men- 
inges, which is proportionate to the amount of obstruction. Extravasations 
of blood and transudation of serum not infrequently accompany the con- 
gestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of scarlet fever 
at the age of eight months, and did not fully recover her health. She con- 
tinued restless and feverish, and had two violent convulsions two weeks 
after the scarlatina. In the following months she had anasarca, and when 
she was nearly a year old another attack of convulsions occurred. Fluctua- 
tion was now observed in the abdomen, and in a few days a sero-purulent 
fluid began to escape from the umbilicus. When this discharge had con- 
tinued eleven days, symptoms of a liquid in the right pleural cavity were 
suddenly developed. She grew weak and emaciated, and finally was seized 
with extreme faintness, with which she died in forty-eight hours, at the age 
of thirteen and a half months. 

At the post-mortem examination a large amount of pus was found in the 
abdominal and right pleural cavities. On the right side of the cranium, 
the sinuses were filled with coagula, and their coats seemed healthy. The 
left lateral and occipital sinuses, the torcular and part of the longitudinal 
sinus, also contained coagula, which extended into the jugular vein. The 
walls of the longitudinal sinus and the internal part of the lateral sinus 
were thickened, and their inner surface had lost its polish and was uneven. 
There was congestion of the brain, with points of extravasated blood. If, 
as is probable, the convulsions were due to some other cause, the only 
symptom which was clearly referable to the thrombosis was the sudden 
faintness. In the four cases of thrombosis occurring in pertussis, already 
alluded to, in which I was enabled to ascertain by post-mortem exami- 
nation the presence and extent of the clots, the symptoms, which were 
apparently due to the thrombosis, were those of cerebral congestion. 
Among these symptoms, stupor, and finally coma were prominent. The 



358 CONGESTION OF BRAIN. 

convulsions which occurred in both cases were apparently a cause, and not 
a result, of the thrombosis. 

Diagnosis It is evident, from what has been said, that thrombosis of 

the cranial sinuses can rarely be diagnosticated with certainty. The pre- 
existence of otitis will sometimes lead us to' suspect its presence, especially 
if the otitis has been accompanied by deep-seated pains. Symptoms of 
cerebral congestion, serous effusion, or apoplexy, occurring in connection 
with otitis, protracted convulsions, or glandular or other tumors situated 
so as to compress the vessels which return blood from the brain, indicate 
thrombosis. 

Prognosis. — The prognosis, in any case, is obviously unfavorable. The 
cause is, ordinarily, permanent, or not readily removed, so that the. clots 
gradually increase. If the cause is a local obstructive disease, death is 
almost certain, since, in nearly every instance, the obstruction is of such a 
nature that it cannot be removed by medical or surgical treatment. It is 
possible that recovery may take place if the clots are few and small, and the 
cause of the thrombosis is mainly feebleness of circulation in consequence 
of a state of debility. We know that clots may liquefy, and their elements 
re-enter the circulation ; but such a result of thrombosis in a cranial sinus, 
if it ever occurs, is rare. The thrombus, by its presence, serves as a point 
of attachment around which more fibrin coagulates, so that the obstruction 
gradually increases till death occurs. 

Treatment Thrombosis should be treated by cool applications to the 

head, in order to diminish the congestion, by stimulants and sustaining 
measures in case the systolic movement of the heart is feeble. Tonics, 
vegetable or ferruginous, are indicated if there is a cachectic state. 



CHAPTER V. 

CONGESTION OF THE BRAIN. 

Congestion of the brain is not peculiar to infancy and childhood, but 
is much more common in these periods of life than subsequently. This is 
due, in a great measure, to the fact that in the young the circulation is 
more readily disturbed by moral as well as physical causes than in the 
adult. 

Congestion of the brain is occasionally primary ; more frequently it oc- 
curs as a concomitant or sequel of some other affection. Diseases, whether 
constitutional or local,. which in the adult have no appreciable effect on 



causes. 359 

the vascularity of the brain, often cause in the child a decided increase of 
blood in this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. The 
former results from a cause which directly affects the brain, and increases 
the flow of blood towards it, or from a cause operating primarily on the 
heart, and increasing the frequency and force of its systolic movement ; 
the latter is due to some obstruction in the course of the circulation, or to 
feeble propelling power on the part of the heart. 

Among the causes which most frequently produce active congestion of 
the brain in the child, may be mentioned blows or falls on the head, ex- 
cessive fatigue or excitement, heat, perhaps sometimes dentition, and also 
various inflammatory and febrile affections, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever are no 
doubt often due, in a great measure, to the irritating effect on the brain of 
the specific principle, whatever it may be, circulating in the blood. Oc- 
curring in inflammatory diseases which are located elsewhere than within 
the cranium, they are often attributed to functional disturbance of the 
brain. The brain, it is said, sympathizes with the affected part through 
the system of nerves which unite them. But observations show that symp- 
toms referable to the brain, arising in the commencement of the essential 
fevers and of the phlegmasia?, are in many instances preceded by, and are 
therefore, doubtless, in greater or less degree dependent on, hyperemia of 
this organ. 

Difficult as it is to ascertain the state of the brain in many diseases in 
which it is involved, we may determine whether or not there is congestion 
in the young child by observing the anterior fontanelle. If it be elevated 
and tense in an acute disease, hyperemia is indicated. Xow, it is often 
unusually prominent in fevers and inflammations, especially in their first 
stages, when cerebral symptoms are present. Its elevation, under such 
circumstances, is obviously coincident with cerebral congestion. 

The acute inflammations which are most likely to be attended by cere- 
bral congestion are those of the mucous surfaces and pneumonia. Severe 
coryza, tracheo-bronchitis, entero-colitis, and colitis, commencing suddenly 
with great febrile excitement, are frequently accompanied in their initial 
stage by active congestion of the cerebral vessels. Cases like the follow- 
ing, which I find in my note-book, are not infrequent. An infant four 
months old had been sick about two days with coryza and bronchitis, when 
I was called to see it; the pulse numbered 156; respiration 64; nursed, 
and was somewhat restless ; cough frequent and dry ; bowels moderately 
relaxed. The mucous membrane of the fauces was injected, and coarse 
mucous rales were present in the chest. The anterior fontanelle rose above 
the level of the cranium, and pulsated forcibly- Soon after convulsions 
occurred, which were relieved by appropriate measures, and on the follow- 



360 CONGESTION OF BRAIN. 

ing day the fontanelle had subsided. The patient gradually recovered 
without any untoward symptom. 

Cerebral congestion and convulsions often mark the initial stage of 
active intestinal phlegmasia. This is especially true of dysentery. The 
little patient, perhaps from the- very inception of the colitis, is drowsy; its 
surface hot ; pulse full and rapid. There is sadden and momentary start- 
ing or twitching of the limbs. The anterior fontanelle, if still open, is 
elevated, and it is not till the lapse of several hours that the cause of these 
symptoms is apparent from the occurrence of bloody stools. 

The causes of passive congestion of the brain are very different from 
those of the active form. A common cause is obstruction in a sinus or 
vein by a fibrinous concretion, or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral congestion 
appeared to be plainly referable to obstruction to the return of blood from 
the brain by the pressure of bronchial glands, enlarged by hyperplasia in 
tubercular disease, these bodies diminishing by external pressure the 
calibre of the venae innominatas or the descending vena cava. Riliiet and 
Barthez have called attention to such cases in the clinical history of tuber- 
culosis. The following case may be cited as an example ; it occurred in 
the infant's service of Charity Hospital, in this city, in April, 1866. 

An infant, about one year old, affected with tuberculosis, both bronchial 
and pulmonary, was observed, during the ten days preceding its death, to 
bore the pillow with its head almost constantly, so as to wear the hair from 
the occiput. This movement of the head was the only prominent cerebral 
symptom. Nothing abnormal was noticed in the appearance of the eyes, 
nor was the stomach irritable. A spasmodic cough and progressive emacia- 
tion attracted attention, but these were referable to the tubercular disease. 
At the autopsy we found the cerebral sinuses, veins, and capillaries greatly 
congested. On tracing the veins which return blood from the brain, an 
inflamed and enlarged bronchial gland was discovered in the angle formed 
by the convergence of the right and left venas innominatae. This gland, 
which contained but a single point of cheesy degeneration, had attained 
such a volume by proliferation of its cells that it pressed upon both ves- 
sels, so that it had obviously retarded the circulation in each, and given 
rise to cerebral congestion. 

Passive congestion often occurs in the infant at birth, either from tedi- 
ousness of the labor or delay in the expulsion of the body after the birth 
of the head. If it is simple congestion, and not congestion with hemor- 
rhage, it soon passes off. Passive congestion of the brain also occurs in 
severe paroxysms of hooping-cough, in which return of blood from this 
organ is temporarily retarded. All are familiar with the congestion which 
occurs in parts external to the cranium, from the severity of the cough ; 
producing epistaxis, extravasations under the conjunctiva, etc. The extra- 
cranial obviously indicates the presence and degree of cerebral congestion. 



ANATOMICAL CHARACTERS. 361 

Those who practise in malarious regions sometimes meet cases. of dan- 
gerous passive congestion of the brain, the result of malaria, occurring 
especially in the cold state of intermittent fever. In these cases the sur- 
face is pallid, its temperature reduced, and the pulse feeble. The blood, 
leaving the peripheral vessels, collects in undue quantity in the internal 
organs, producing congestion of the brain, as well as of the thoracic and 
abdominal viscera. In the child with malarial disease, in whom there is 
less vigor of constitution than in the adult, death not infrequently occurs 
in this passive congestion. Two such cases have occurred in my practice, 
although in this latitude the malarial maladies are mild in comparison 
with the type which they present in many parts of the United States. 

Symptoms The symptoms of active congestion of the brain are stupor, 

great heat of head, throbbing of carotids, restlessness when aroused, twitch- 
ing of the limbs, and perhaps convulsions. There is also sometimes in- 
tolerance of light, and the anterior fontanelle, if open, pulsates strongly. 
In passive congestion many of the symptoms are the same as in the active 
form. Stupor, twitching of the limbs, and fretfulness or irritability when 
the patient is disturbed, are common, ordinarily without increase of tem- 
perature ; the surface may, indeed, be cool, and the face is not flushed nor 
the eyes injected. The strong pulsation and elevation of the anterior fon- 
tanelle, so conspicuous in active congestion, are — the former always, the 
latter often — lacking. In both forms there is tendency to constipation. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, but it 
is not difficult, unless in exceptional instances, to determine which are due 
to the congestion, and which to the antecedent and coexisting pathological 
state. 

Anatomical Characters In active congestion there is an excess of 

arterial blood in the brain and its membranes. The arteries, to their 
minutest branches, are seen to be full, presenting the bright hue of oxy- 
genated blood. In passive congestion the sinuses and veins are distended. 
The pia mater, choroid plexus, and the vessels of the brain, have a darker 
appearance than in active congestion. In both forms of congestion, if they 
continue for a little time, other anatomical changes occur. If there is 
great distension of the capillaries, these vessels are apt to give way, and 
we find here and there little patches of extravasated blood. In other cases 
the over-distension is relieved by the transudation of the serous portion of 
the blood through the coats of the vessels. The cephalo-rachidian fluid is 
then found in excess external to the brain and in the ventricles. 

Prognosis — The duration and the result of congestion of the brain de- 
pend, in great measure, on the nature of the cause. If the cause is trivial, 
as mental excitement, fatigue, exposure to heat, there is usually prompt 
relief if the condition of the patient is understood and properly treated. 
If the cause is general or constitutional, as one of the essential fevers or 



862 CONGESTION OF BRAIN. 

hooping-cough, or if it is local, but its seat external to the cranium, the 
prognosis, so far as the congestion is concerned, is not unfavorable, if there 
is a timely and judicious use of remedies. The most unfavorable cases are 
those in which the cause is seated in the encephalon, and those in which 
there is some obstructive disease in the course of the circulation. Con- 
gestion occurring from a structural change within the cranium is, from 
the nature of the cause, without remedy, and ordinarily fatal. Obstruc- 
tive diseases of the circulatory system, wherever located, being for the 
most part permanent, give rise, as a rule, to incurable congestion. 

Congestion of the brain, if it is not relieved in a few hours, becomes 
less and less amenable to treatment. It soon passes beyond the resources 
of our art, and ends in coma ; it is seldom protracted beyond a few days. 
Extravasations of blood common in active congestion, and serous effu- 
sion common in the passive form, diminish the chances of a favorable 
result. 

Treatment The indication for treatment in active congestion is plain. 

Measures should be employed which have a derivative effect from the 
brain. Unless there is an asthenic primary affection, in the course of 
which the congestion is developed, active purgation is required. A saline 
purgative is ordinarily preferable. If the stomach is irritable, there is no 
better purgative than calomel. In all cases of active congestion, what- 
ever the cause, the bowels should be kept open. It is often better not to 
wait for the tardy action of a cathartic, but to give at once an enema of 
soap and water or salt and water. External derivative agents are also in- 
dicated. A warm mustard foot-bath, sinapisms to the back of the neck or 
chest, and to the feet, and cold applications to the head, are measures 
which should never be neglected. 

This treatment, if employed early, will relieve the congestion in a large 
proportion of cases ; but if there is no improvement, if the child is robust, 
and if the primary affection be such as does not contraindicate loss of 
blood, leeches should be applied to the temples or some part of the head. 
If after the lapse of some hours cerebral symptoms continue, apoplexy or 
serous effusion has probably occurred. Congestion is then no longer the 
prominent lesion, and it is proper to designate the disease by another 
name. 

The treatment appropriate to passive congestion is somewhat different > 
cold applications to the head, and those of a derivative nature to the ex- 
tremities, are useful. As this form of the disease is not primary, but is 
dependent on some antecedent pathological state, it is evident that it can 
only be treated successfully by removing or obviating as far as possible 
the cause. But the nature of the various obstructions to the intracranial 
circulation is such that our ability to accomplish this end is very limited. 

If the cause is constitutional, or if it be some disease in the neck or 
chest, it may sometimes be partially or even wholly removed, but if seated 



INTRACRANIAL HEMORRHAGE. 363 

within the cranium it is beyond our control. In general, it may be said 
that depletion is not required or tolerated in passive congestion, and stimu- 
lants are often needed. 



CHAPTER VI. 

INTRACRANIAL HEMORRHAGE (MENINGEAL HEMORRHAGE. 
CEREBRAL HEMORRHAGE). 

Hemorrhage within the cranium is not very infrequent in infancy 
and childhood ; and there is no part of the encephalon, whether the me- 
ninges or brain, in which it does not sometimes occur. If the blood is 
extra vasated upon the surface of the brain or between the meninges, the 
disease is designated by writers meningeal apoplexy ; if in the substance 
of the brain, cerebral apoplexy. Extravasation may also occur in one of 
the lateral ventricles. This may, for convenience, be described as a form 
of meningeal apoplexy. 

Causes — Apoplexy is usually (there is an exception) preceded by con- 
gestion. If the congestion increases to a certain degree, the distended 
capillaries give way and extravasation of blood results. Therefore the 
causes of congestion which have been enumerated in the preceding article 
are, in great measure, those of apoplexy. Recent microscopic examina- 
tions have demonstrated that the corpuscular elements of the blood may 
escape from capillaries without rupture. While, therefore, it is probable 
that intracranial hemorrhage in early life commonly occurs from a rupture, 
its occasional occurrence through the walls of the capillaries must be ad- 
mitted. 

Intracranial hemorrhage is not infrequent in the new-born. It results 
in them from tediousness of the birth and severity of the labor-pains. 
At first there is extreme congestion of the meningeal and cerebral vessels 
corresponding with that of the scalp and face. This congestion, continu- 
ing, soon ends in extravasation of blood. In some of these cases forceps 
have been used to effect the delivery, but it is doubtful whether the useof 
instruments materially increases the congestion or the amount of extrava- 
sation. Certainly, in a large proportion of intracranial as well as supra- 
cranial hemorrhages of the new-born, instruments have not been used. 
An additional cause of the hemorrhage is, in some instances, the use of 
ergot, which, by producing strong and continuous pains, interrupts the 
placental circulation and increases the congestion of the foetal veins and 
the capillaries. 



364 INTRACRANIAL HEMORRHAGE. 

In infants a few days old intracranial hemorrhage may result from 
that rapid and fatal disease, tetanus infantum. The hemorrhage is 
preceded by intense passive congestion, which the tetanic rigidity and 
spasms produce by obstructing respiration and circulation. Few cases of 
tetanus infantum occur without more or less extra vation of blood, either 
meningeal or cerebral. Another cause of this disease is obstruction in 
the vessels which return the blood from the brain. The various structural 
changes which produce this obstruction, in different cases, have been 
sufficiently described in our remarks on cerebral congestion and throm- 
bosis. 

The congestion which precedes hemorrhage, when occurring under the 
conditions described above, is passive. 

Among the causes which produce hemorrhage through the intermediate 
state of active congestion may be mentioned great mental excitement, of 
Avhich M. Legendre relates a case, lengthened exposure to the sun's rays, 
an example of which Rilliet and Barthez have seen. It is also said that 
compression of the aorta by an enlarged liver or an abdominal tumor has 
sometimes produced meningeal or cerebral hemorrhage, by causing an 
increased afflux of blood to the head. A very important cause to which 
I have not alluded, is that general state of the circulatory system which 
is designated by the term purpura hemorrhagica. This sometimes results 
from the anti-hygienic conditions in which the child is placed. In other 
instances it results from some antecedent disease, protracted and debili- 
tating, which has produced a profound alteration in the state of the blood 
and the vessels. The capillaries become less firm and elastic, and easily 
give way, so that in such patients ecchymotic points are ordinarily found 
in different parts of the system. The diseases which occasionally end in 
this hemorrhagic diathesis are numerous. I have known it to occur after 
measles, scarlet fever, and smallpox. It is also an occasional sequel of 
chronic diarrhoea, of intermittent and typhoid fevers, and of rachitis. 

Anatomical Characters Hemorrhage in or upon the brain, in 

infancy and childhood, differs in important particulars froin that occur- 
ring in adult life. In the adult, and more so as life advances, the arteries 
become less distensible and more brittle, so that when hemorrhage occurs 
it is usually from one of these vessels. In early life, on the other hand, 
the blood does not ordinarily escape from an artery, but, as has been 
stated, from the capillaries. The extravasation is not, therefore, so rapid 
and violent, and is not attended with such laceration and injury of sur- 
rounding parts, in infancy and childhood, as at a subsequent age. In the 
adult the hemorrhage commonly occurs in the substance of the brain. 
The flow of blood from the ruptured artery separates the brain-substance, 
producing a cavity in which a clot forms. This constitutes the usual form 
of apoplexy in the adult. In the first years of life, on the contrary, the 
extravasation is commonly from the meninges, and the symptoms to which 



ANATOMICAL CHARACTERS. 365 

the effused fluid gives rise are for the most part due to its mechanical 
effect. Cases of hemorrhage in the substance of the brain constitute a 
small minority, unless during the days immediately succeeding birth. In 
early life, therefore, on account of its greater frequency, meningeal hemor- 
rhage is a disease of more importance than cerebral, and its anatomical 
character should be carefully studied. 

In meningeal hemorrhage the extravasation may be between the cranium 
and dura mater, upon the viseeral layer of the arachnoid, in the meshes 
of the pia mater, or in a lateral ventricle, from rupture of the capillaries 
in the choroid plexus. Much the most common seat is external to the pia 
mater in the so-called cavity of the arachnoid ; the blood escaping in this 
situation spreads uniformly in all directions. It soon separates in two 
portions, the solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in the vicinity 
of the extravasated blood preserve their normal appearance, or are but 
slightly injected ; the clot gradually becomes extended on all sides, so as 
to form a lamina at the seat of the extravasation, thinner at its circum- 
ference than centre, and at first of a dark-red color. The color gradually 
fades, and the lamina, becoming smooth and polished, and at the same time 
more and more attenuated, finally resembles the arachnoid in appearance. 
Its diameter varies in different cases from a few lines to two or three or 
more inches. M. Tonnele relates two observations in which the adven- 
titious membrane extended over the superior surface of both hemispheres, 
and in one of them, also, over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, but 
its usual seat is the vertex. The next most frequent locality is the base of 
the brain. The subsequent history of the delicate membrane into which 
the clot is gradually transformed is interesting. It often extends so as to 
cover more space than was occupied by the extravasated blood, and its 
edges are then scarcely distinguishable, in consequence of their extreme 
tenuity, and their close resemblance to the arachnoid. The attachments of 
this membrane, so far as it forms any, are usually to the parietal surface 
of the arachnoid. Sometimes a portion of the membrane is attached, while 
the rest lies free, bathed on either side by the liquid portion of the blood 
which still remains from the extravasation. According to M. Legendre, 
in the most favorable cases, the serum is absorbed, and the membrane 
which has resulted from the clot, and which I have described, becomes in- 
timately adherent to the internal surface of the dura mater. It forms an 
integral part of this membrane, and there only remain a little thickening 
and increased opacity, indicating the seat of the extravasation. The health 
is fully re-established. 

But the result in other cases is as follows : The serum is not absorbed, 
and the newly formed membrane, uniting at points with the inner surface 



6bb INTRACRANIAL HEMORRHAGE. 

of the dura mater, or its arachnoidal covering, incloses the fluid so as to 
produce a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the membrane, 
especially if large, unites in such a way as to give rise to more cysts than 
one. The size of the cyst varies, according to the quantity of fluid, which 
may be only a few drachms or several ounces. Rilliet and Barthez report 
a case in which there was a pint of fluid lying over each hemisphere, there 
being two cysts. If the cranial bones are not united, so that they yield to 
the pressure, the size of the cranium is increased, and if the extravasation 
is confined to one side, an inequality results, and the symmetry of the head 
is destroyed. The fluid which causes the enlargement of the head in such 
cases, is in part the serum of the extravasated blood, and in part a subse- 
quent secretion. 

Various writers relate cases of ventricular hemorrhage. Valleix met it 
in an infant that died at the age of two days. In the Edin. Jour, of Med. 
and Surg., October, 1831, an interesting case is related. A boy, nine 
years old, died of hemorrhage in both ventricles, and also at the base of 
the brain and in the spinal canal. In the Nursery and Child's Hospital 
of this city, the post-mortem examination was made of an infant who died 
at the age of one month. In the posterior cornu of the left lateral ventri- 
cle were two clots, elongated and black, one larger than the other. In the 
corresponding cornu, on the opposite side, was a smaller clot. A similar 
post-mortem appearance was observed at the autopsy of a young infant in 
the infant service of Charity Hospital. A dark crescentic clot lay in each 
posterior cornu. The clot, if remaining a long time , undergoes degenera- 
tion. In the case of an adult, in which a year had elapsed after the 
extravasation, I found it to contain crystals of cholesterin and carbonate 
of lime. 

Cerebral hemorrhage, or hemorrhage in the substance of the brain, 
may occur at any time in infancy and childhood. The blood is sometimes 
extravasated in points, here and there, over the entire organ, or a part of 
the organ ; in other cases it is extravasated in one or perhaps two cavities, 
as in the ordinary form of apoplexy in the adult. In the first form of 
cerebral hemorrhage, or that in which the blood escapes from numerous 
points through the brain, there is evidently little laceration or injury of 
the organ. The brain-substance surrounding the hemorrhagic points some- 
times preserves the usual appearance. It is white and firm. In other 
cases it presents a reddish or yellowish appearance, and is softened to the 
depth of a line or two. If the hemorrhage occur in a cavity, as in apo- 
plexy of adults, the nerve-fibres are evidently torn and separated, and there 
is more or less compression of the surrounding brain-substance. Unless 
the disease is of long standing, the cavity contains a dark and soft clot 
bathed with serum, which has a reddish or a yellowish-red appearance. 
The brain in the immediate vicinity of the cavity is sometimes softened. 



SYMPTOMS. 367 

Rilliet and Barthez state that they have seen eight cases of cerebral hemor- 
rhage of the capillary form ; ten cases in which the hemorrhage was in 
cavities ; and in two of the eighteen both forms were present. In five of 
those in which the form was capillary the disease was limited to portions 
of the brain, while in the remaining three the hemorrhagic points were 
found in nearly every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether the 
hemorrhage be capillary or in a cavity, there is, in most cases, as pre- 
viously stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of hemorrhage is 
believed by some to be greater in the new-born than at any other period 
of life. Valleix relates four cases of intracranial hemorrhage occurring at 
this age, two of which were cerebral, one ventricular, and in the other the 
extravasation was in the cavity of the arachnoid. Mignot has published 
eight cases occurring in the new-born, in two of which the hemorrhage 
was in cavities in the cerebrum ; in three, in the lateral ventricles ; and in 
three, external to the brain. If the same proportion be observed in other 
statistics, one in three of the cases of intracranial hemorrhage occurring in 
the new-born is cerebral. 

Symptoms The symptoms in intracranial hemorrhage are not uni- 
form ; they vary according to the seat as well as the quantity of the effused 
blood. In some cases the extravasation occurs without such symptoms as 
would direct attention to the brain. When the hemorrhage occurs at the 
time of birth, in consequence of the strong and long-continued labor-pains, 
the infant is often born apparently dead. This is due partly to the hemor- 
rhage, partly to the great congestion of the brain which precedes and 
accompanies the hemorrhage. Resuscitation is gradual and difficult. The 
infant's features are livid, and perhaps swollen ; its respiration is gasping, 
and both pulse and respiration are slow. Its cry is feeble, with but slight 
movement of the facial muscles, and the lungs are but partially inflated ; 
the eyelids are closed, and the limbs almost motionless. By artificial 
respiration and by friction, the pulse and breathing maybe rendered more 
frequent, but the latter remains irregular and gasping. Finally, the limbs 
grow cold, the surface, from a state of lividity, becomes pallid, and death 
occurs in profound coma. M. Cruveilhier made many observations at the 
"■Maternity" in reference to the death of new-born infants, and he believes 
that one-third of those who die in birth, at the full period, die of apoplexy. 
I have made post-mortem examinations in a few cases, when death had 
occurred from this cause, and in all the hemorrhage was meningeal. One 
of these was born on the 30th of December, 1864. The birth was delayed 
by unusual projection of the promontory of the sacrum, so that finally 
the application of forceps was necessary. The infant was apparently still- 
born, but by persistent efforts on the part of the physician who assisted it 
was resuscitated so as to live several hours, though with constant embar- 



368 INTRACRANIAL HEMORRHAGE. 

rassment of respiration and with lividity. At the autopsy a large ex- 
travasation of blood was found in the cavity- of the arachnoid, over a con- 
siderable part of the convexity of the brain, and the substance of the brain 
was deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Valleix relates the 
case of an infant who died of pneumonia at the age of three and a half 
months. Its birth had been protracted and difficult, but was completed 
without the use of instruments. It had had during its entire life paralysis 
of the right side. At the autopsy a clot was found near the base of the 
right thalamus opticus, evidently existing from birth. Around the clot 
the brain was softened to the depth of some lines, and was of a bluish-red 
color. A very similar case is related by M. Vernois. An infant lived 
forty-nine days with paralysis of the left side, and died of pneumonia. At 
the autopsy a hemorrhagic excavation in the process of cicatrization was 
found behind the right corpus striatum and the thalamus opticus. 

Intracranial hemorrhage occurring from accidents of birth is generally 
attended by marked symptoms, such as have been described. But when 
it occurs subsequently to birth, whether in infancy or childhood, the symp- 
toms vary greatly in different cases, and are generally obscure. I will 
briefly state the symptoms which have been observed in both the cerebral 
and meningeal forms of this disease. First, the cerebral. Sedillot relates 
the case of a child seven and a half years old, whose bare head had been 
exposed several hours to the sun's rays. Suddenly, after a paroxysm of 
anger, it was seized with great pain, corresponding with the posterior and 
inferior fossas of the cranium. It uttered piercing cries, and died in a 
quarter of an hour. A clot was found in the right lobe of the cerebellum. 
Richard Quinn (Rilliet and Barthez) gives the history of a boy nine years 
old, who in playing with a hoop suddenly stopped, carried his hands to 
his head, and fell backwards unconscious. Three or four hours after- 
wards, when examined, he was found pale, surface cool, respiration slow 
and at times stertorous, pulse 50 to 60 per minute; the left arm was flexed, 
the left leg paralyzed ; the right leg and arm convulsed ; right pupil 
strongly dilated, the left contracted. He died seven hours after the com- 
mencement of the attack, and a large clot was found in the centrum ovale 
on the right side. 

Rilliet and Barthez relate the following case from Campbell. A boy 
with good previous health was suddenly seized about 7 A. M. with repeated 
vomiting, and in an hour and a half with violent convulsions ; he rolled his 
eyes and uttered inarticulate cries ; pulse frequent and hard ; pupils con- 
tracted ; trunk and lower extremities cool. In the afternoon he presented 
symptoms of compression of the brain, such as dilatation of the pupils, 
frequent and feeble pulse. Death occurred in the evening, and a hemor- 
rhagic cavity was found occupying the right middle lobe of the cerebrum. 



SYMPTOMS. 369 

Guibert relates a case of extravasation in the superior part of the right 
hemispheres of the brain in a boy fourteen years old. The principal symp- 
toms were feebleness of the limbs, inability to walk, cephalalgia, involun- 
tary evacuations, fever, grinding of the teeth, rigors severe and prolonged, 
lividity, loss of intellectual faculties, dilatation of the pupils, insensibility, 
to light, stertorous respiration. Death occurred in about an hour. 

Rilliet and Barthez narrate the history of a girl two years old, who, 
after an attack of measles, was taken with convulsions accompanied with 
fever and prostration. The convulsive movements affected especially the 
eyes and upper extremities ; the right leg was immovable ; the left pupil 
dilated. These symptoms resulted from hemorrhage in the corpus striatum 
and opticus thalamus. The same authors relate also the case of a girl, 
seven years old, who died with a large apoplectic cavity in the left thalamus 
opticus. The symptoms were headache, convulsive movements, loss of con- 
sciousness, delirium, vomiting and constipation, convergent strabismus. 
These symptoms nearly disappeared, but in a few days the headache re- 
turned, with strabismus and a slight drawing of the face towards the left ; 
on the twenty-seventh day there were some convulsive movements of the 
right eye, with paralysis of the arm. Finally contractions of the arms 
occurred, with acceleration of pulse, irregular breathing, dilated pupils, 
paralysis, and retraction of the head, followed by death on the forty-eighth 
day. 

These cases, and those from Valleix and Yernois, which have been re- 
lated in our remarks on hemorrhage of the new-born, are sufficient to show 
the character of the symptoms in that form of cerebral hemorrhage in 
which the extravasated blood forms a cavity in the interior of the brain. 

If the amount of extravasation is large, and the substance of the brain 
is much lacerated and compressed, death may occur almost immediately, 
and, therefore, without symptoms, or before it is possible to determine 
whether or not symptoms are present. If the disease is not so speedily 
fatal, the symptoms, as appears from the above cases, are headache, con- 
fusion of thought, or even insensibility, cries, sometimes piercing, cold ex- 
tremities, pallor, slow and perhaps stertorous respiration, convulsive move- 
ments followed by paralysis, or convulsions affecting one or more limbs, 
with paralysis of others, pupils contracted or dilated, sometimes one con- 
tracted and the other dilated, strabismus, rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they are 
not all present in any one case. Those which are generally present, and 
on which we mainly rely for diagnosis, are headache, convulsive move- 
ments, paralysis, confusion of thought, irregularity in the pupils, and 
strabismus. 

In the capillary form of cerebral hemorrhage there is usually some 
complication, so that it is not easy to determine how far symptoms are due 
to the hemorrhage, and how far to the coexisting pathological state. 
24 



370 INTRACRANIAL HEMORRHAGE. 

There are, indeed, but few published observations of capillary hemor- 
rhage in the substance of the brain uncomplicated with meningeal hemor- 
rhage, hemorrhage into a ventricle, or some other and distinct disease, but 
so far as I have been able to ascertain the symptoms referable to this form 
of extravasation, they are as follows : The child is drowsy ; fretful when 
disturbed ; it perhaps moans. There are sometimes slight convulsive move- 
ments and partial paralysis. If there is considerable extravasation, the 
respiration is irregular and sighing. Death occurs in coma, occasionally 
preceded by convu'sions. Taupin relates the case of a child nine years 
old, who died with this form of hemorrhage, accompanied by softening 
of the brain. The disease began at night, with delirium, agitation, and 
piercing cries. In the morning the patient lay in bed, drowsy, not com- 
plaining of pain, and not replying to questions ; pupils dilated, and in- 
sensible to light ; left eye half open during sleep, and its axis changed ; 
eyebrows contracted ; face pale ; mouth open ; had no convulsions, but 
transient stiffening of the limbs, during which the thumbs were firmly 
compressed by the fingers ; senses unimpaired, but the face drawn to the 
right; deglutition difficult ; pulse small, irregular, and feeble ; respiration 
32, sighing. In the evening he had rigidity of the limbs and back, and, 
finally, was taken with general convulsions, in which he died at eleven 
o'clock. The hemorrhagic points in this case were numerous. A boy 
five years old, whose case is described by Killiet and Barthez, died of this 
disease, pneumonia, and white softening of the intestine. During the last 
five days there were cerebral symptoms, the chief of which were drowsi- 
ness, fretfulness when disturbed, and moaning without apparent cause. 
Another child, whose case is described by Rilliet and Barthez, died at the 
age of four years, with cerebral capillary hemorrhage, accompanied by 
yellow softening. Six months before death he had general convulsions, 
followed by spasmodic movements of the left side. These subsided, but 
the left side remained feeble. 

In Meningeal hemorrhage there are often convulsions, general or 
partial, in some patients tonic, in others clonic. When partial, the con- 
vulsive movements may only occur in the muscles of the face and eyes. 
With the spasmodic muscular action is a degree of drowsiness and irrita- 
bility. Paralysis, so common in the apoplexy of the adult, and not in- 
frequent, as we have seen, in the cerebral form of early life, is sometimes, 
but not ordinarily, present in meningeal hemorrhage. Instead of paraly- 
sis, there are vomiting, some febrile action, thirst, and loss of appetite. 
The symptoms are different, however, according to the exact seat of the 
hemorrhagic extravasation, and the duration of the disease. If the ex- 
travasation end in the formation of a cyst, the symptoms are those of 
hydrocephalus. The following condensed history of cases which I have 
selected as typical, will give us a clearer idea of the history and course of 



DIAGNOSIS. 371 

the various forms of meningeal hemorrhage than can be imparted by a 
narration of symptoms : — 

M. Tonnele relates the case of a child who was taken with faintness and 
convulsive movements. On the following day the trunk and inferior ex- 
tremities became rigid ; deglutition was painful ; the pupils were largely 
dilated, immovable; face pale; pulse feeble and intermittent. Death 
occurred the same day. The dura mater was distended. A layer of 
coagulated blood, of great thickness, extended over the convexity of each 
hemisphere. The veins ramifying in the superior part of each hemisphere 
were distended with coagulated blood. The hemorrhage was in the 
meshes of the pia mater. Drs. Lombard and Pan chard, of Geneva, 
relate a somewhat similar case. A child, thirteen months old, was con- 
valescing from inflammation of the bronchial and intestinal mucous sur- 
faces, when it was seized with general convulsions ; the mouth and eyes 
were open, and the eyes directed upwards; pupils contracted; pulse fre- 
quent and irregular. The convulsions abated somewhat, but soon reap- 
peared with violence. The patient became insensible, and died nineteen 
hours after the commencement of cerebral symptoms. The extravasated 
blood covered the upper surface of both hemispheres. From the above 
cases we see the symptoms and the course of meningeal hemorrhage, when 
the extravasation is so large that death speedily results. In protracted 
cases of meningeal hemorrhage, there is either a gradual disappearance of 
symptoms and return to health, or, circumscribed hydrocephalus occurring, 
the symptoms of that disease arise. 

Diagnosis It is evident, from what has been stated, that the diag- 
nosis of intracranial hemorrhage is attended with unusual difficulty, since 
the symptoms of this disease occur also in other and distinct pathological 
states. The history of the case, and especially the character of the cause, 
if ascertained, will aid in diagnosis. If there has been an obvious deter- 
mination of blood to the brain, or some known obstruction to the return 
of blood from that organ, the persistence of cerebral symptoms would 
justify i.s in concluding that either serous or sanguineous effusion had 
supervened on a state of congestion. The points of differential diagnosis 
between apoplexy and meningitis are the sudden and full development of 
symptoms in one case, the gradual commencement and gradual increase of 
symptoms in the other ; differences also of symptoms in certain respects ; 
for example, as regards febrile reaction, constipation, etc. 

There is one symptom in cerebral hemorrhage which is of great diag- 
nostic value, namely, paralysis. Its presence affords strong evidence that 
there is extravasation of blood, and probably in a cavity in the substance 
of the brain. If the extravasation end in the formation of a cyst, the 
symptoms and appearances of hydrocephalus, which, after a time, arise, 
throw light on the nature of the disease. 



372 INTRACRANIAL HEMORRHAGE. 

Prognosis There can be no doubt that many cases of intracranial 

hemorrhage occur and terminate favorably without the nature of the dis- 
ease being suspected. In such cases the amount of extravasated blood is 
small or moderate. In several published cases in which the accuracy of 
the diagnosis was shown by post-mortem examinations, the patients were 
convalescing from the hemorrhage when they succumbed to intercurrent 
diseases. If, however, the amount of extravasated blood is such as to give 
rise to those symptoms which have been described, the prognosis is unfa- 
vorable. Recurring convulsions, and persistent stupor from which it is 
difficult to arouse the patient, are unfavorable symptoms. If the convul- 
sions cease, and consciousness return, even if there is paralysis, the result 
may be favorable. 

Treatment — The proper treatment in intracranial hemorrhage de- 
pends on the state of the patient, the time which has elapsed since the ex- 
travasation, and the degree of it, as shown by the nature and severity of 
the symptoms. If, as is often the case, the patient is robust, and is visited 
soon after the commencement of the attack, cold applications should be 
made to the head, mustard to the back of the neck and perhaps chest, and 
derivation should be produced by mustard pediluvia. In many cases, 
especially in active congestion, it is advisable to apply leeches to the tem- 
ples, and the bowels should be opened by a stimulating enema. In active 
congestion, also, prompt purgation by salines or other cathartics, is some- 
times of great importance. The object of such treatment is to relieve con- 
gestion of the cerebral and meningeal vessels, and thereby prevent further 
extravasation of blood. If the congestion be active, the pulse continue 
full and frequent, and the face be flushed, it is proper in many cases to 
control the action of the heart by a sedative. For this purpose the tincture 
of aconite root may be given in doses of one drop to a child five years old, 
repeated in three hours if necessary, or veratrum viride may be used. If 
the stupor or convulsions continue after sufficient time has elapsed for the 
patient to receive the full benefit of the above remedies, more active coun- 
ter-irritation is required. Cantharidal collodion should be applied behind 
each ear. If the hemorrhage occur from passive congestion, or in a ca- 
chectic state of system, active depressing remedies should not be employed. 
External derivatives are of service, as well as cool applications to the head, 
and we should attempt, so far as possible, to remove the cause of the con- 
gestion and hemorrhage. If it depend on a cachectic state, tonic or other 
remedies calculated to relieve this state are indicated. The hemorrhage 
from such a cause is apt to be in points in the substance of the brain, or in 
moderate quantity over the surface of this organ, and by a timely use of 
constitutional remedies possibly we may prevent further extravasation of 
blood and increase the chance of the patient's recovery. 

If a cyst result from the hemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



CONGENITAL HYDROCEPHALUS. 373 



CHAPTER VII. 

CONGENITAL HYDROCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain, or more frequently in its interior. 
It is due to some vice in the development of the brain or its membranes, 
or to a pathological state occurring in them during intra-uterine life. This 
disease is ordinarily apparent from the symptoms and appearances at birth, 
but not always. Occasionally nothing unusual is observed in the shape of 
the head or aspect of the infant till after the lapse of some weeks, when 
the characteristic physiognomy begins to appear. In these cases the disease 
is still congenital, as there is every reason to believe that the abnormal 
state to which the excessive production of fluid is due existed from birth. 
In cases of arrested or partial development of the brain, as, for example, 
when a considerable portion of the hemispheres is absent, there is often an 
unusually large quantity of fluid which serves merely as a compensation 
for the lack of brain. I do not regard such cases as examples of hydro- 
cephalic disease, since the effect of the fluid is not injurious, but rather 
useful. I restrict the term congenital hyprocephalus to those cases in 
which the brain is complete, or, if incomplete, the quantity of fluid is 
more than sufficient to supply the deficiency. 

Anatomical Characters According to M. Breschet, the fluid in 

congenital hydrocephalus may be — 1st, between the dura mater and the 
cranium ; 2d, between the dura mater and the parietal arachnoid ; 3d, in 
the cavity of the arachnoid ; 4th, in the ventricles ; 5th, between the 
arachnoid and the brain. 

In a large majority of hydrocephalic patients the seat of the effusion is 
the ventricles. As the quantity of fluid increases, the pressure from with- 
in gradually unfolds the convolutions of the brain, at the same time pro- 
ducing expansion of the cranial arch. When the amount of fluid is con- 
siderable, and it becomes so in the course of a few weeks or months, the 
hemispheres are spread out in a thin lamina on either side, gradually de- 
creasing in thickness from the base of the cranium to the vertex, where 
the brain -substance is sometimes so thin as to be scarcely perceptible. 
Complete absence of brain in this situation, namely, at the vertex, even 
in extreme cases of expansion and flattening of the hemispheres from the 
pressure of the liquid, is rare, though the brain-substance at this point is 
sometimes almost as thin as either of the membranes, so that the wall of 



374 



CONGENITAL HEDROCEPH ALUS. 



the sac is translucent. The membranes which surround the brain do not 
usually undergo any alteration, except such as arises from the distension. 
The falx cerebri sometimes disappears, and sometimes the meninges pre- 
sent a whiter hue from maceration than in health. The distension also 
causes such an expansion of the pia mater that it becomes very thin, 
and in places scarcely visible, but its presence in every point can be 
demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it 
ordinarily occurs. I saw this infant when it was a few days old, and ex- 
amined it from time to time till its death. The parents are healthy and 
have other healthy children. This infant when nine days old began to 
have clonic convulsions of a mild form in the muscles of the face, neck, 
and limbs, which recurred almost daily till the age of six weeks, and 

Fig. 19. 




sometimes every five or ten minutes. When the convulsions ceased in 
the sixth week, the head was observed to enlarge, and its excessive 
growth continued till death, which occurred at the age of seven months 
and one week. While the volume of the head progressively increased, 
the trunk and limbs emaciated. At death the occipitofrontal circum- 
ference of the head was nineteen and a half inches ; the vertical from 
auditory meatus to meatus thirteen and a half inches. 

The changes which the cranial bones undergo, both in their chemical 
character and in their shape, in hydrocephalic patients, if the amount of 
fluid is considerable, are interesting and remarkable. The base of the 
cranium undergoes little change, but those portions of the frontal, parietal, 
and occipital bones which constitute the arch are expanded in all direc- 



ANATOMICAL CHAKACTERS. 375 

tions, while they become much thinner. There is deficiency of lime in 
their constitution, so that their organic elements are greatly in excess. 
This renders them flexible and semi-transparent. Notwithstanding the 
expansion of the bones, there are usually interspaces between them, of 
greater or less size, according to the amount of fluid. 

The scalp, being stretched by the pressure underneath, becomes tense 
and thin, and is scantily covered with hair. The veins which ramify in it 
are unusually prominent and large, and the head is elastic on pressure, from 
the amount of liquid beneath. In the common form of congenital hydro- 
cephalus, namely, that in which the liquid is in the interior of the brain, 
the shape of the orbital plates of the frontal bone is changed, so that the 
eyeballs have a downward direction. This change in the axis of the eyes 
occurs at an early period, and it continues through the entire disease, be- 
coming more and more marked as the quantity of liquid increases. If the 
amount be large, the lower part of the cornea is buried under the under 
eyelid, while the conjunctiva is visible between the cornea and the upper 
eyelid. The persistent downward direction of the eyes is characteristic 
of this disease, and, in connection with enlargement of the head, is an 
important diagnostic sign. 

If we examine the interior of the cavity after the fluid is evacuated, we 
will find at its base the parts which lie in the floor of the lateral ventri- 
cles, but changed in appearance in consequence of pressure. The cornua 
are enlarged, and the thalami optici and corpora striata are flattened. 
In the early stages of the disease, when the amount of fluid is small, there 
is probably no absorption or destruction of parts in the interior of the 
brain. The various portions of this organ retain nearly their normal 
relation to each other. As the quantity of fluid increases, the foramen 
of Monro, which unites the lateral ventricles, becomes enlarged, the septum 
lucidum which separates them disappears, and the two ventricles form a 
common cavity. In most fatal cases we find this single large cavity. The 
surface which surrounds the cavity occasionally presents a whitish or semi- 
opaque appearance, which has led to the belief, that at a period antece- 
dent to birth there was subacute inflammation of this surface, and hence 
the effusion. 

The bones of the face are ordinarily less developed than in healthy 
children of the same age, so that the disproportion between the head and 
face becomes a marked peculiarity. The shape of the forehead and face 
is nearly triangular. 

The foregoing remarks in reference to the anatomical characters of con- 
genital hydrocephalus refer in the main to cases which have continued for 
a considerale time, so that their characteristic features are well marked. 
In very young infants, in whom the disease is still recent, similar anatom- 
ical characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of con- 



376 



CONGENITAL HYDROCEPHALUS. 



Fig. 20. 



formation, especially with spina bifida. The two, when coexisting, are 
only parts of the same disease ; the large quantity of cerebro-spinal fluid 
preventing the spinal canal from closing during foetal development. 

The fluid in congenital hydrocephalus consists largely of water, in the 
proportion even of 99 parts in 100. In addition to this element, there are 
traces of albumen, chloride of sodium, phosphate and carbonate of soda, 
and osmazome. 

I have had an opportunity to witness only one post-mortem examination 
in a case of congenital hydrocephalus in which the liquid was exterior to 
the brain. This case was under observation in the children's service of 
Charity Hospital, in 1866. Full notes and measurements of the head 
were taken, which, unfortunately, were mislaid or lost. The infant had 
congenital syphilis, and had a pallid, strumous appearance. The shape 
and relative size of the head are seen in the accompanying figure, from a 
photograph. While the whole head was enlarged, there was a relative 
excess of development in the part between and above the ears. The axis 
of the eyes was not at all changed, and the vision was good. The appear- 
ance corresponded so closely with descriptions of hypertrophy of the brain 
that this was supposed to be the anatomical state. Antisyphilitic treatment 

was employed, and the syphilitic eruptions had 
nearly disappeared, when diarrhoea supervened, 
followed by death. At the autopsy a quantity 
of transparent or light straw-colored liquid, 
estimated at six or seven ounces, was found 
exterior to the brain, in the great cavity of the 
arachnoid, lying mostly over the superior sur- 
face of the organ. There was no excess of 
liquid in the ventricles, and the brain, though 
of good size, was not abnormally large, nor 
did it possess the firmness which is present in 
true hypertrophy. 

All cases of congenital hydrocephalus may 
be embraced in two groups, namely, that in 
which" the liquid is in the interior of the brain, and that in which it lies 
exterior to the organ. Liquid primarily in the arachnoidean cavity per- 
meates the meshes of the pia mater, and lies in part underneath it, or this 
delicate membrane may be ruptured. Four of the groups, therefore, 
described by Breschet, may properly be reduced to one, namely, those 
groups in which the liquid lies under, between, or external to the men- 
inges. It is probable that some of the cases which led to Breschet's 
classification were examples of acquired circumscribed hydrocephalus, the 
result of extravasation of blood. In this form of hydrocephalus, as is 
stated elsewhere, an adventitious membrane forms external to the liquid, 
becoming in time thin and delicate, and often bearing a close resemblance 




SYMPTOMS, 377 

to the normal membrane (especially the arachnoid), for which it is some- 
times mistaken. 

Symptoms If there is a considerable amount of hydrocephalic fluid 

prior to the birth of the child, so that the head is abnormally large, partu- 
rition is seriously interfered with. The scalp and mininges may become 
ruptured by the severity of the pains so that the fluid escapes. If this 
does not occur, the labor is often necessarily instrumental. Whether the 
liquid is present before birth or accumulates subsequently to it, the ten- 
dency is to an increase of the quantity, and a corresponding enlargement 
of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily, and has its evacuations with the regularity of other 
children. Not many weeks, however, elapse, in the majority of cases, 
before defective nutrition is apparent. 

While the volume of the head increases, other parts are imperfectly 
nourished and stunted in their growth. Emaciation is common of the 
neck, trunk, and limbs, associated with progressive feebleness. In the 
last stages of this disease there is more or less vomiting with constipation. 
If there were previously the ability to support the head, it is now lost, and 
the erect position is no longer possible. In marked cases, when there is 
great disproportion between the head and the rest of the system, there is 
frequently not even the ability to rotate the head on the pillow. As long 
as the cranial bones yield readily to the pressure from within, and there 
is no compression of the brain, the function of this organ is not seriously 
impaired. The child recognizes its mother or nurse, and it can be amused 
like other children, though easily fatigued. The state of the senses is dif- 
ferent in different cases, and sometimes at different stages of the same 
case. The sight and hearing in some are perfect, in others impaired ; 
while in others still they are good at first, but gradually become obscured 
and lost. It is said that the sense of smell may be perverted so that 
agreeable odors are unpleasant, and vice versa. Many, reaching the age 
at which children begin to walk, cannot walk, or, if they do, it is with a 
tottering, unsteady gait. 

When the liquid increases to that extent, and it usually does sooner or 
later, that the brain begins to be compressed, dangerous cerebral symp- 
toms arise. The child becomes drowsy, and takes less notice of objects. 
Spasmodic muscular contractions and finally convulsions occur. The pupils 
act feebly or irregularly by light, or one is more dilated than the other. 
Strabismus also occurs. As death approaches, the eclampsia, partial or 
general, becomes more frequent, and is succeeded by stupor from which 
the patient cannot be aroused. 

The following case, which I copy from my note-book, is an example of 
the common form of congenital hydrocephalus. It will give an idea of 
-the ordinary course of this disease, and show the difficulty which we meet 



378 CONGENITAL HYDROCEPHALUS. 

with in its treatment. Female, born November 9th, 1859, with the aid 
of forceps. At birth the fontanelles were unusually large, the cranial 
bones separated, and the aspect in a marked degree hydrocephalic. She 
nursed at first, but, the mother's milk failing, she was afterwards bottle- 
fed. At the age of four months her head, which had increased faster than 
her general growth, measured from one auditory meatus to the other, over 
the vertex, seventeen inches ; the occipitofrontal circumference, twenty- 
three inches. At this time she manifested considerable intelligence, being 
able to distinguish her mother from other persons, though the head was so 
large that it was necessary to support it constantly on a pillow. From the 
age of four to six months the operation of tapping was performed six times 
with a small hydrocele trocar, by Prof. Stephen Smith, at a point near 
the coronal suture, and from one inch to one inch and a half from the 
sagittal. At each operation an amount of fluid varying from twelve 
ounces to one pint was removed, and the head then covered with strips of 
adhesive plaster, so as to form a complete cap. It was necessary, how- 
ever, within the twelve hours succeeding each operation, to loosen the 
dressing on account of either the occurrence of convulsions or symptoms 
premonitory of them. The head, within a week subsequently to each 
operation, regained its former size, and, as there was no permanent benefit, 
this treatment was discontinued. She finally died of entero-colitis at the 
age of ten months and five days. 

At the autopsy the distance from one auditory meatus to the other was 
twenty and a quarter inches ; the occipitofrontal circumference, twenty- 
six and a quarter inches. The anterior fontanelle measured antero-pos- 
teriorly four and three-fourths inches; transversely, seven and three-fourths 
inches. The parietal bones were separated from each other to the distance of 
two or three inches, and they measured in length nine and one-half inches. 

On opening the cranial cavity, seven pints, by measurement, of trans- 
parent fluid escaped, exposing a vast open space, at the bottom of which 
were the parts which constitute the floor of the ventricles, somewhat 
changed in shape, and from them, on either side, the hemisphere was 
spread in a lamina, so as to cover the internal surface of the cranial 
bones. The laminae near the base of the brain measured in thickness 
from half an inch to one inch, and they gradually became thinner on 
approaching the vertex, at which point the brain-substance was exceed- 
ingly thin, so as to be scarcely demonstrable. 

The brain had its normal vascularity and consistence, and the cerebel- 
lum, medulla oblongata, the base of the brain, and cranial nerves pre- 
sented their usual appearance. On folding the brain together, it had the 
size, shape, and aspect of this organ in its ordinary development. Noth- 
ing unusual was observed in the membranes except their great expansion. 
The above case corresponds in its general features with most cases met in 
practice. 



TREATMENT. 379 

Diagnosis. — The ordinary form of congenital hydrocephalus, that in 
which the liquid occupies the interior of the brain, can, in most cases, be 
readily diagnosticated. If there is only a moderate amount of liquid, it 
may be confounded with hypertrophy of the brain. In hydrocephalus 
there is commonly more rapid growth and greater expansion of the head ; 
moreover, the enlargement occurs equally on all sides, while in hyper- 
trophy, though all parts of the cranial vault are expanded, the enlarge- 
ment is more at the vertex than elsewhere. The hydrocephalic head 
yields more readily to pressure than the hypertrophied, and often commu- 
nicates a fluctuating sensation. Moreover, in the ordinary form of hydro- 
cephalus, the change in the axis of the eyes described above is an important 
diagnostic sign. In rachitis the volume of the head is often considerably 
enlarged, due sometimes, in part at least, to a deposit of calcareous matter 
on the exterior of the cranial bones. The differential diagnosis is based 
on the shape of the head, round in one, square or with prominences in the 
other, on palpation, direction of the eyes, etc. The smaller the amount 
of liquid, the greater the liability to error of diagnosis ; but if the amount 
is inconsiderable and not increasing, little treatment is required, except 
hygienic and tonic, which is also proper in both hypertrophy and rachitis. 
If the liquid is exterior to the brain, as in the case represented on page 
376, diagnosis may be difficult, but such cases are infrequent. 

Prognosis This is unfavorable. The amount of liquid in congenital 

hydrocephalus, as already stated, commonly increases. The most favorable 
result is no increase, or but slight, in the quantity, while the natural growth 
of the infant continues, and thus the disproportion between the head and 
the rest of the system gradually disappears. This result is exceptional. 
Ordinarily, while the quantity of fluid increases, the nutrition of the body 
and limbs is more and more deficient. The patient, if not cut off by some 
intercurrent disease, finally succumbs with cerebral symptoms produced 
by pressure of the fluid. The majority of those affected with congenital 
hydrocephalus die in infancy, but some enter childhood, and occasionally 
one reaches even adult life. Cases of recovery have been reported, but if 
they were genuine, the disease was evidently mild, and the amount of liquid 
small or moderate. 

Treatment — It is a proper question, in many cases, whether anything 
should be done to relieve the hydrocephalic infant besides attending to its 
general health. The anxiety of parents, however hopeless the nature of 
the case if left to itself, reported recoveries, and the fact that we have 
medicines which in many instances diminish the amount of liquid in the' 
internal cavities, incline us to the use of therapeutic measures. 

We may attempt to diminish the quantity of fluid by the use of diuretics. 
Digitalis, squills, nitrate and acetate of potash, have been used. Probably 
the most efficient diuretic in these cases is iodide of potassium. This 
may be given in doses of one to two grains every two hours to an infant of 



380 ACQUIKED HYDROCEPHALUS. 

six months. Constipation, if present, should be relieved by an occasional 
purgative. If it is tolerated, we may partially prevent the expansion of 
the head by a close-fitting cap. For this purpose strips of adhesive plaster 
about one-third of an inch in width, should be applied so as to cover the 
entire head. The proper way of applying these is as follows : First, one 
strip from each mastoid process to the outer part of the orbit on the oppo- 
site side; secondly, from the back of the neck, along the longitudinal 
sinus, to the root of the nose ; thirdly, over the whole head, so that the 
different strips will cross each other at the vertex ; and, lastly, a strip long 
enough to pass three times around the head should be applied, passing 
above the eyebrows, the ears, and below the occipital protuberance. Too 
tight an application should be avoided, as it may give rise to convulsions 
or other cerebral symptoms. If the cap can be tolerated, and the general 
health is good, the prospect is more favorable ; but usually, from the in- 
crease in the quantity of fluid, it is necessary in a few days to remove or 
loosen the plasters in order to prevent convulsions. If this treatment is 
not successful, we may finally resort to tapping. The mode of performing 
this operation has already been indicated in the case which I have detailed. 
No appreciable good result has followed the use of irritating or sorbefa- 
cient applications to the head. Nutritious diet and attention to the general 
health are requisite. 



CHAPTER VIII. 

ACQUIRED HYDROCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those who 
at birth are well formed and free from disease. Pathologists call this ac- 
quired hydrocephalus. It is in nearly all cases the result of disease, which 
is located sometimes within the cranium, but often in other parts of the 
system. 

Causes The diseases within the cranium which most frequently pro- 
duce serous effusion are the meningeal inflammations, both simple and 
tubercular, tumors or other causes which obstruct the venous circulation, 
and hemorrhagic effusion ending in the formation of cysts. Prolonged 
passive congestion often ends in transudation of serum through the coats 
of the capillaries. Therefore, all those causes of congestion, except such 
as have a transient or momentary effect, may be regarded as causes of 
serous effusion. 

Among the diseases external to the cranium which produce serous effu- 
sion within or upon the brain, may be mentioned retropharyngeal abscess, 



ANATOMICAL CHARACTERS. 381 

tuberculization or inflammation of the bronchial glands, scarlet fever, 
and certain affections of an exhausting nature, especially protracted diar- 
rhceal maladies. In at least five cases which have fallen under my notice, 
and in which post-mortem examinations were made, the cause was en- 
larged tubercular bronchial glands, which, by pressure on the venae in- 
nominate, so retarded the flow of blood from the brain as to cause con- 
gestion and effusion. The causative relation of these glands to cerebral con- 
gestion is more fully described in our remarks in reference to this disease. 
Dropsy of the brain is common in protracted infantile diarrhoea, as in 
advanced cases of intestinal catarrh of the summer months in the cities. It 
is preceded and accompanied by passive congestion of the cerebral veins 
and sinuses, due in part to feebleness of circulation in consequence of the 
exhausted state of the patient, and in part to the wasting of the brain, 
which always gives rise to more or less passive congestion, unless in young 
infants, in whom the cranial bones become depressed and override each 
other. Dropsy of the brain resulting from scarlet fever, and that peculiar 
circumscribed dropsy which results from hemorrhagic effusions, are de- 
scribed elsewhere. 

A few cases have been related by different observers, Abercrombie 
among others, in which dropsy of the brain seemed to be essential. No- 
thing abnormal was observed, with the exception of serous effusion. But 
the reports of such cases are, for the most part, meagre ; and, as Barrier 
has well said, we are not to accept such cases as examples of essential 
dropsy of the brain, unless the post-mortem inspection is so complete as to 
render it certain that there was no pathological state which might cause 
the dropsy. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and, therefore, the shape of the 
head is not materially altered. If .it occur at an early age, before there 
is firm union, there may be expansion of the cranial arch, as we sometimes 
observe in the circumscribed hydrocephalus resulting from hemorrhage. 
The effusion in acquired hydrocephalus occurs over the surface of the 
brain, in the subarachnoid space, or in the lateral ventricles. In the 
dropsy of protracted diarrhoeal maladies, I have rarely failed to find the 
liquid over the whole superior surface of the brain as well as at its base. 

The quantity of fluid in this disease is not large. In the majority of 
cases it does not exceed four ounces, and is often much less. It is trans- 
parent, or it has a slightly yellowish tinge. The membranes of the brain 
sometimes present their normal appearance, but in other cases they are 
injected. The brain itself, in some instances, has an injected appearance 
from passive congestion of the veins and capillaries ; but in others, when 
there has been more or less compression of the brain, there is no more than 
the ordinary, or even less than the ordinary vascularity, and the convolu- 
tions are somewhat flattened. 



382 ACQUIRED HYDROCEPHALUS. 

Symptoms — The symptoms of the pathological state, which gives rise 
to the dropsy, precede and accompany those which are referable to the 
dropsy itself. The dropsy declares itself by symptoms which are alarming 
from the first. 

In children old enough to speak, or manifest intelligence, there may be 
at first complaint of headache. The child is irritable, its mind confused 
or wandering at times, or there is actual delirium. After a time drowsi- 
ness occurs. The head seems too heavy for the body, and is buried in the 
pillow. In fatal cases the features become pallid, the pupils sluggish, and 
perception and consciousness are gradually lost. The child lies in pro- 
found sleep, which increases. There are now often convulsive movements 
partial or general, and these soon end in coma, in which the patient dies. 

Prognosis — Acquired hydrocephalus commonly ends unfavorably. 
The prognosis depends not only on the quantity of liquid, but on the na- 
ture of the cause. If the cause be venous obstruction within the cranium 
or thorax, as we have no means of removing it, death is inevitable. If it 
be an exhausting disease, as entero-colitis or scarlet fever, although the 
case is not absolutely hopeless, the prospect is still unfavorable. It is only 
favorable when the quantity of effused fluid is small, the system not much 
reduced, and the primary disease mild. "When acquired hydrocephalus 
arises from meningeal apoplexy, the case is apt to be chronic. The symp- 
toms and termination of this form of the disease are very similar to those 
in congenital hydrocephalus. 

Treatment The treatment in acquired hydrocephalus must vary 

somewhat in different cases, according to the nature of the disease on which 
it depends. I shall indicate the treatment, in part at least, in the descrip- 
tion of these diseases. Occasionally the condition of the patient is such 
that there is little to encourage us in the employment of any remedial 
measures. In vigorous children, if acquired hydrocephalus occur in con- 
nection with symptoms which indicate too active a circulation, moderate 
abstraction of blood from the temples at an early period may be useful, 
but cases requiring such depletory measures are rare. These cases require 
cold applications to the head ; the bowels should be opened, and deriva- 
tives should be applied to the feet and back of the neck. 

If the congestion be of a passive character, as when the circulation is 
obstructed by tumors or otherwise, benefit may still be derived from cold 
applications to the head, and derivatives to other parts. In most cases of 
suspected dropsy of the brain, unless the patient is in such a hopeless state 
that all treatment is obviously futile, vesication should be produced behind 
the ears. I prefer cantharidal collodion for this purpose. In addition to 
this treatment, diuretics should be employed, unless there is too great pros- 
tration, or the course of the disease is so rapid that no benefit can result 
in consequence of the tardy action of these agents. The best diuretics are 
the acetate of potash and iodide of potassium. 



MENINGITIS, SIMPLE AND TUBERCULAR. 



CHAPTER IX. 

MENINGITIS, SIMPLE AND TUBERCULAR. 

The most interesting and important disease of the cerebro-spinal system 
in early life, is that which is now designated meningitis. It is not infre- 
quent. The mortuary statistics of this city show that it is the cause of 
death in from one in twenty-five to one in fifty of the entire number of 
deaths, the proportion varying somewhat in different years. 

In 1768, the attention of the profession was particularly called to this 
disease, by Dr. Whytt, of Edinburgh. This observer, and the pathologists 
succeeding him, forming their opinion of meningitis from its most promi- 
nent anatomical character, namely, serous effusion, believed it a dropsy. 
They accordingly designated it acute hydrocephalus. During the last 
thirty years the profession have come to regard the disease as inflamma- 
tory, and hence the name by which it is now known, and which is believed 
to express its true pathological character. 

Sometimes meningeal inflammation in children is idiopathic. In other 
instances it occurs in those affected by tuberculosis, and in many, if not in 
all such patients, there are tubercles in or under the meninges, which ex- 
cite the inflammation in the same manner as in the lungs they cause pneu- 
monitis or pleuritis. Therefore two forms of meningitis are recognized, 
namely, simple and tubercular. 

Prior to 1868 I had preserved records of forty-five fatal cases of menin- 
gitis, some occurring in my private practice, and the remainder in insti- 
tutions of this city with which I have been connected. Post-mortem 
examinations were made and recorded in thirteen of them. Twenty-five 
were under the age of one year, of which fifteen were apparently well 
when the meningitis commenced, belonging for the most part to healthy 
families; three were feeble and cachectic, but apparently without tuber- 
cles ; and five had miliary tubercles in various organs, as shown by post- 
mortem examination. The condition of the other two was not recorded. 

Of the twenty who were over the age of one year, the majority, namely, 
thirteen, presented a decidedly cachectic or a strumous aspect before the 
meningitis occurred, and a considerable number had symptoms of pul- 
monary tubercles. These statistics, as far as they go, show r that simple 
meningitis predominates under the age of one year, and I may add 
eighteen months, while over that age the tubercular cases are in excess. 

The belief has prevailed in the profession, that tubercular meningitis 



3S4 MENINGITIS, SIMPLE AND TUBERCULAR. 

does not occur in young infants. This idea is therefore fallacious, although, 
as has been stated, meningitis under the age of one year is oftener inde- 
pendent of tubercles or the tubercular diathesis than associated with them. 
Bouchut, speaking in reference to tubercular meningitis, says: " Up to 
this period it was not believed that this disease existed in young children, 
for no mention is made of it in the works of Denis and Billard. Still its 
existence at this age is, nevertheless, incontestable. MM. de Blache, 
Guersant, Rilliet and Barthez, and Barrier have observed several ex- 
amples of it, and I have collected six cases of this disease in the practice 
of M. Trousseau. The youngest child was only three months old, and the 
eldest had arrived at the end of his second year. No statistics can be 
based on so small a number of facts ; the only value they have consists in 
their overruling an opinion falsely accredited in medical science." I have 
witnessed the post-mortem of five cases of tubercular meningitis occurring 
in children under the age of one year, as is seen from the above statistics, 
and the age of one of these was only four months. In two, perhaps I 
should say three, of the five the presence of tubercles in the meninges was 
not positively demonstrated; but in all of the five cases miliary tubercles 
were present in the lungs and other organs, so that I did not hesitate to 
consider the meningeal inflammation of a tubercular character. 

In patients over the age of eighteen months, although the proportion of 
tubercular to simple cases is larger than under this age, the excess is not 
so great, according to my statistics, as the remarks of some observers would 
lead us to suppose. There can be no accurate statistics of tubercular 
meningitis without careful post-mortem examination of the state of the 
brain and other organs in each supposed case, and this examination some- 
times shows the meningitis to be simple, when the symptoms and physical 
signs had indicated its tubercular character. As an example, may be men- 
tioned a case which occurred in the children's service of Charity Hospital, 
in March, 1868. The infant died at the age of twenty months, having 
had a cough of moderate severity at least three weeks before death, and 
symptoms of meningitis about four days. It was considerably wasted, and 
was supposed to have tuberculosis. At the autopsy, no tubercles were found 
in any part of the body, but parts of both lungs were hepatized. A fibrinous 
deposit, varying in thickness, was found over the pons Varolii, the optic 
commissure, along the fissures of Sylvius, over the superior surface of the 
anterior half and also upon the superior lobe of each cerebral, hemisphere. 
As a careful examination failed to discover any tubercles, the meningitis 
was considered simple. Those who make these examinations, failing to 
find tubercles in the lungs and other organs in which they usually occur, 
should examine the lymphatic glands, for cheesy glands may be the cause 
of the formation of tubercles in the meninges while the organs of the trunk 
remain unaffected. The presence of cheesy glands in the absence of vis- 
ceral tubercles, and with granulations upon the meninges, small, covered 



PATHOLOGICAL ANATOMY. 385 

with fibrin, and of a doubtful character, goes far towards establishing the 
tubercular nature of the meningitis. Thus in one such case which I ex- 
amined the meningitis seemed to be due to cheesy bronchial glands, and I 
therefore considered it tubercular. 

Age The following table gives the age in meningitis, simple and 

tubercular, in forty-two cases in my collection : — 

Cases. _ Age. 

1 .... 2^ weeks. (Autopsy.) 

2 .... 2 months. 

20 ... . From 3 to 12 months. 

10 . . . . "1 year to 2 years. 

5 " 2 years to 5 " 

4 Over 5 years. 

42 

Eilliet and Barthez have also published statistics of the age in menin- 
gitis. Their cases were observed chiefly in hospital practice, and the 
result is somewhat different. 

In thirty-two cases of simple meningitis observed by these authors, eight 
were under the age of one year, six from two years to five, and eighteen 
over the age of five years. In ninety-eight cases of tubercular meningitis, 
there were two under the age of one year, fifty-one between the ages of 
one year and five, thirty-eight between the ages of five years and ten, and 
seven between ten and fifteen years. 

Pathological Anatomy This differs considerably in different cases. 

The dura mater is usually unaffected or is affected secondarily. In many 
cases it retains its normal appearance, its internal surface remaining 
smooth and polished, while in others it is more or less injected, and its 
internal surface dim or lustreless. The free surface of the pia mater,, 
formerly designated the visceral arachnoid, is in a great part of its extent 
unchanged, but is often hypersemic, or dry and cloudy, or opaque, over 
the seat of the inflammation. Exudation does not occur upon the free 
surface of the pia mater, however intense the inflammation. 

In both simple and tubercular meningitis the inflammatory action occurs 
in the pia mater. In its meshes, or underneath them, occur the lesions 
which characterize the disease, and to which other lesions are secondary. 
Tubercular meningitis is most frequently basilar, or is basilar chiefly and 
primarily, although the inflammation may extend along the sides of the 
hemispheres. The meningitis is ordinarily most intense around the pons 
Varolii in the subarachnoid space and along the fissures of Sylvius, for the 
tubercular neoplasm occurs chiefly at the base of the brain along the course 
of the vessels. In simple meningitis, the inflammation may also occur at 
the base. ■ It may in young infants be quite diffuse, and of little intensity 
in any one place, producing, in addition to hyperemia of the pia mater, 
slight cloudiness and a moderate or slight escape of leucocytes from the 
25 



386 MENINGITIS, SIMPLE AND TUBERCULAR. 

blood, these (pus cells) being perhaps visible only under the microscope. 
In meningitis, due to extension of inflammation from an otitis media, the 
inflammation is intense, confined to the portion of the meninges nearest 
the ear, and is often attended by inflammation of adjoining brain-substance, 
with perhaps the formation of an abscess. If the cause is exposure to the 
sun's rays, the meningitis is apt to be at the summit of the brain. 

The exudation of fibrin is greatest along the course of the vessels, and in 
the depressions between the convolutions, and the opacity is most marked 
in these situations. Pus, when present, is often semi-solid, from the 
small proportion of liquor puris which it contains, even in recent cases. 
If the disease have continued several days, the liquor puris may be mostly 
absorbed, and the pus-cells becoming shrivelled, irregular, and aggregated, 
may resemble closely the cheesy transformation of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not usually 
attain much thickness, but by its opacity it conceals from view the brain 
underneath. If it occur in the fissures of Sylvius, the anterior and middle 
lobes are united by it. It is usually infiltrated through the substance of 
the pia mater. Sometimes little masses of variable size, often not as large 
as a pin's head, appear at the point of inflammation. These masses are 
firm, of a whitish color, or a light yellow, and their number varies in dif- 
ferent cases. They consist of a firm, homogeneous substance, containing 
granular matter, and cells which often bear a close resemblance to tuber- 
cle-corpuscles, but are distinct. These corpuscular bodies are plastic 
nuclei or plastic cells, often shrunken. It is seen, then, that there are 
two morbid products which may be mistaken for tubercle : one, pus which 
has been in great measure deprived of its liquid element, and which may 
resemble cheesy tubercular matter, the other, plastic neuclei collected 
in little bodies, so as to resemble the ordinary from of crude tubercle. I 
once carried to one of the best microscopists and pathologists of this city 
some of the exudation from a case of meningitis, the cellular element 
in which could not readily be distinguished from shrunken tubercle-cor- 
puscles. The exudation was from a child two years and eight months 
old, with good health previously to the meningitis ; without tubercles in 
any part of the body, with parents healthy, and with no predisposition 
to tubercular disease. This microscopist, not knowing the history of the 
case, or character of the family, and ignorant, like all of us at that 
time, of the true tubercle-cell, pronounced the exudation tubercular after 
a careful examination with the microscope. Bouchut says : " The whitish 
miliary granulations which are observed on the surface of the pia mater 
have a certain consistency and tenacity which render them difficult to tear 
with the needles used for the preparation for the microscope. These bodies 
are formed : 1. Of fibro-plastic elements, whether nuclei or fusiform fibres ; 
oval-shaped cells are generally present, but not always. The nuclei are 
oval or spherical, generally very small — that is to say, they hardly exceed 



PATHOLOGICAL ANATOMY. 38 i 

in diameter 0.008 mm. to 0.009 mm. The presence of these little spherical 
nuclei must be insisted on, because, with a less power than 550 diameters, 
it would be sometimes impossible to establish the differences which separate 
them from the elements of tubercle ; the fusiform fibres are small and rare. 
2. There exists a considerable quantity of amorphous homogeneous matter, 
in which minute granulations are scattered ; it is very dense, and keeps the 
other elements strongly united together, so that it is difficult to isolate 
them completely. 3. Vessels are very rarely observed ; the fibres of cel- 
lular tissue are also rare, or altogether wanting." 

There being two microscopic elements which are distinct from tubercular 
formations, but are liable to be mistaken for them, namely, shrivelled pus- 
cells and plastic nuclei, more or less altered, it is seen, in part at least, 
why the old writers, and some of a more recent date, either hold that all 
meningitis is tubercular, or that there are comparrtively few cases of the 
simple form. 

On the other hand, there are cases of true tubercular meningitis which, 
even with a pretty careful microscopic examination, might be, and prob- 
ably often have been, regarded as simple. In order to a better under- 
standing of this subject, I may be permitted to repeat certain facts already 
stated in the article on tuberculosis. The views of pathologists in reference 
to what is the primary form of tubercle, and what is and what is not tuber- 
cular matter have recently undergone a great change. It is now believed 
that the tubercle-cell is a round, pale, slightly granular cell, identical in 
appearance with the normal cell of the lymphatic glands, being in the 
average somewhat smaller than the white corpuscle of the blood ; that it 
is produced mainly from the nuclei of the connective tissue by prolifera- 
tion ; that it is vitalized like other cells, and, of course, has functional 
activity ; that the true, the living cell, is found only in the so-called gray, 
semi-transparent tubercle. It is furthermore believed, that what has here- 
tofore been considered the tubercle-cell, namely, the irregular, sometimes 
angular, sometimes oval cell — without, indeed, any typical form — may be 
a dead, shrivelled, and altered tubercle-cell, or a dead, shrivelled, and 
altered pus or other cell. If, therefore, such cells are found in the meshes 
of the pia mater, we cannot determine from the microscope their true 
character. We can only form our opinion in reference to their nature 
from concomitant circumstances, or from discovering in connection with 
them the true tubercle-cell. Those products which have been designated 
crude tubercle and tubercular infiltration, contain these shrivelled cells, 
or shrivelled nuclei ; and they may have a tubercular origin, or, on the 
other hand, an inflammatory origin, without either the tubercular product 
or diathesis. 

In the tuberculosis of young children I have found, in a large propor- 
tion of cases in which I have had an opportunity to make post-mortem 
examinations, miliary tubercles disseminated through the lungs, and per- 



388 MENINGITIS, SIMPLE AND TUBERCULAR. 

haps other organs, in small masses, many of them not larger than a pin's 
head, and some occurring as mere specks scarcely visible. These minute 
tubercular formations have ordinarily been semi-transparent, and some- 
times even transparent like minute drops of water, and containing the 
true and unchanged tubercle-cell. Now if in such a case meningitis 
occur, we may find the tubercle-cell in or with the fibrin at the base of 
the brain. But failure to find it, even with protracted microscopic exami- 
nation, does not prove its absence from this locality, for I consider it 
almost impossible to discover in the midst of the fibrinous exudation such 
minute points of tubercular matter as are seen in the lungs, liver, or else- 
where. In view of these facts, I know no better rule for the practitioner, 
who cannot command the time for thorough microscopic examinations, 
than to consider as tubercular all cases of meningitis in which tubercles 
or cheesy glands are observed, in whatever part of the system, and con- 
sider as examples of simple meningitis all those cases in which no tubercles 
are apparent in the meninges or in any other organ of the trunk. 

The pia mater is often firmly adherent to the brain at the seat of inflam- 
mation, so that on raising it a portion of the brain may be detached and 
removed with it. The extent of the inflammation varies much in different 
cases. There may in extreme cases be pretty general inflammation of the 
pia mater. In cases of such extensive meningitis, the symptoms are apt 
to be severe and the course of the disease rapid. Thus, in the month of 
April, 1866, a girl eleven years of age, in the Protestant Episcopal Orphan 
Asylum of this city, had complained occasionally of dizziness, but was 
otherwise in good health, cheerful, and Avith excellent appetite, till Thurs- 
day, when she was affected with vertigo, more persistent than previously, 
and with headache. At 2 P. M. on the following day she was seized with 
general convulsions, and continued insensible or nearly so, with occasional 
convulsive movements, till Monday, when she died comatose. The pia 
mater at the vertex, sides, and base of the brain had a cloudy appearance, 
and underneath it, in places, was a thick creamy substance in small quan- 
tity, which, examined by the microscope, proved to be pus, the largest 
amount being near the pons Varolii. There was no tubercle under the 
meninges or elsewhere, and no appreciable fibrinous exudation. The in- 
flammation in this case was obviously intense. The only additional lesions 
noticed were moderate congestion of the brain and an increase in the 
quantity of the cerebro-spinal fluid. 

If the disease is protracted three or four weeks, which is rare, or even 
less time, the exuded substance may undergo further changes, such as 
occur in simple exudations in other parts of the system. Thus, on the 
30 tli of April, 1860, we made the post-mortem examination of an infant 
at the Nursery and Child's Hospital, who had symptoms of cerebral dis- 
ease, it was stated, for several weeks, but the exact time was not ascer- 
tained. Prominent among the symptoms referable to the cerebro-s^ .nal 



ANATOMICAL CHARACTERS. 389 

system towards the close of life were the hydrocephalic cry and rigidity 
of the neck. The appearance at the autopsy was remarkable. The an- 
terior half of the brain was completely encased in a deposit which had 
nearly the appearance of lard. It filled the fissures of Sylvius, and ap- 
peared slightly on the anterior aspect of the cerebellum. Examined under 
the microscope, this substance was found to contain numerous cells, among 
which could be distinguished some resembling pus-cells, but nearly all had 
undergone more or less fatty degeneration. Here and there was seen a 
large cell containing numerous small oil-globules, the compound granular 
cell of pathologists. 

The brain itself in meningitis is usually injected. On making an in- 
cision through it, red points are seen upon the cut surface, which indicate 
the seat of the congested vessels. The inflammation rarely extends to the 
walls of the ventricles, but the choroid plexus is injected. In exceptional 
instances pus or fibrin is found in the lateral ventricles. In the infant, 
two and a half weeks old, whose case has already been alluded to, about 
two ounces of purulent fluid escaped on opening the left ventricle. A 
small amount of liquid of a similar character was contained in the right 
ventricle. The distension of the lateral ventricles with serum is one of 
the common results of meningitis. This fluid is clear or straw-colored, or 
it is turbid in consequence of being mixed more or less with the softened 
brain-substance. The quantity does not exceed two, three, or four ounces, 
and is often not more than one ounce or an ounce and a half. The dis- 
tension of the two ventricles is ordinarily uniform, as they are united by 
the foramen of Monro, but now and then one ventricle is found more dis- 
tended than the other. If there is considerable effusion, the brain is 
compressed and the convolutions have a flattened appearance, unless the 
cranial bones are still separated so as to yield to the pressure. If the 
sutures and fontanelles are open the cranial arch is expanded, sometimes 
quite perceptibly to the eye. From the same cause the anterior fonta- 
nelle, if open, is elevated. The foramen of Monro is enlarged according 
to the amount of effusion, and the portions of the brain which separate 
the ventricles are sometimes lacerated. In many cases the cerebral sub- 
stance surrounding the lateral ventricles is softened. The softening is 
found in all degrees, from the least appreciable deviation from the normal 
consistence to a state of dimuence so that the brain presents the appear- 
ance of cream. Hypotheses have been advanced to explain the cause of 
this change in consistence, which are not entirely satisfactory. Whatever 
the explanation, the fact is attested by all observers, though there are ex- 
ceptional cases. Thus Dr. West has records of the condition of the brain 
in fifty-nine cases, in thirty-seven of which there was considerable soften- 
ing, and in the remaining twenty-two the consistence was normal. 

Since a majority of the cases of meningitis in children are basilar, and 
portions of all the cerebral nerves lie at the base of the brain, it is easy to 



390 MENINGITIS, SIMPLE AND TUBERCULAR. 

understand why the functions of these nerves are so seriously impaired in 
this disease. Compression of these nerves, or extension of inflammation to 
their sheaths, affords explanation of many of the symptoms, as the sighing 
respiration, abnormalities of the eye, etc. 

Although the above remarks relating to the anatomical characters of 
meningitis are applicable to a large majority of the cases, I must confess 
that I have sometimes been disappointed at the autopsies of young infants 
who died with all the symptoms of simple meningitis in not finding more 
lesions. Moderate hyperemia of the pia mater, its slight opacity or cloudi- 
ness at the base of the brain or elsewhere, with the presence of a few 
wandering white corpuscles, without any fibrinous exudation, with no in- 
crease of liquid external to the brain, but a considerable increase of it in 
the lateral ventricles, and hyperemia of the choroid plexus, with nearly 
natural appearance and consistence of the brain, have in .some instances 
been the only lesions when I had expected to find marked anatomical 
changes. 

I am fully convinced from my own observations that, in some instances, 
physicians who supposed that they were treating tubercular meningitis, 
and at the autopsies discovered within the cranium tubercles, without any 
inflammatory lesion, but with a larger increase of the cerebro-spinal liquid, 
have been treating cases in which in addition to the meningeal tubercles, 
which were latent, the bronchial glands were tubercular and cheesy, so 
that by their increased size they compressed the venaa innominatae within 
the thorax, thus preventing the free flow of blood from the brain, and 
causing, as I have elsewhere stated, cerebral and meningeal congestion, 
with more or less transudation of serum, but with no meningitis. 

Causes. — The causes of simple meningitis are not fully ascertained. 
Active cerebral congestion frequently occurring, however produced, ap- 
pears to be one of the most common causes in young infants. In at least 
three instances I have known meningitis occur in infants between the 
ages of four and eight months, after severe and protracted bronchitis, 
which had been attended with the usual heat of head. The disappearance 
of eruptions upon the scalp, at or immediately before the commencement 
of the meningitis, has often been observed. I have witnessed it at the 
commencement of simple meningitis, as well as of meningitis which, if not 
tubercular, occurred at least in a decidedly scrofulous state of system. 
The direct effect of the solar rays upon the head, and the prolonged action 
of a high atmospheric temperature, even without direct exposure of the head 
to the sun, are common causes during the summer months in New York 
city. I once attended a child with this disease who had been much ex- 
posed bareheaded to the direct rays of the sun in August and September, 
and at his death, which occurred towards the close of the hot weather, 
found hypereemia, opacity, and fibrinous exudation in the pia mater at the 
summit of the brain, while the base of the brain seemed nearly or quite 
normal. 



PREMONITORY STAGE. 391 

In the Jahrbiich f. Kinderkrank for October, 1875, Dr. Soltmann, of 
Breslau, reports three cases, in which intense cerebral hyperaemia, and 
probably meningitis, occurred from solar heat. In all three children the 
attack was sudden, the febrile movement and heat of head intense, and the 
progress rapid. The first had convulsions, the second automatic move- 
ments, and the third, the oldest, aged four years, when able to speak, 
complained of violent headache. 

The statistics of New York city show that congestive and inflamma- 
tory maladies of the brain and its covering are more common during July 
and August, which are the months of maximum atmospheric heat, than 
in other months of the year. For example, in July and August, 1875, 
one hundred and sixty-seven died of these maladies, or one in every nine 
and eight-tenths who died from local disease, while during the entire 
year only seven hundred and ten died from the same, or one in every 
fifteen who perished from local diseases. 

July, 1876, in New York city, was characterized by excessive and 
long-continued atmospheric heat, the temperature in the Central Park 
Observatory in the shade never falling below 61°, though never above 
98°, and having a mean of 82.9°. There was also unusual dryness of 
the atmosphere, since during the entire month prior to July 30th, there 
were only fourteen hours of rain, with a rain-fall of .77 of an inch, and 
the average atmospheric humidity was represented by 65, saturation being 
denoted by 100. During this month I treated in my private practice four 
fatal cases, all between the ages of two and seven years, which I diagnos- 
ticated meningitis, none of them presenting any symptoms of otitis or 
tuberculosis. It would seem that the atmospheric heat had much to do 
with the development of the disease in these cases. One died in two 
days, but in the others there was the usual duration. 

A not infrequent cause, especially among the strumous families of the 
cities, is otitis media, and caries of the petrous portion of the temporal 
bone, the inflammation extending to the meninges. Meningeal tubercles 
as a cause of meningitis, have been sufficiently alluded to. 

Premonitory Stage — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases of 
both the simple and tubercular forms, which I have seen, there was a pro- 
dromic period, varying from a few days to several weeks. The symptoms 
of this period are obscure, and are apt to be mistaken for those of other 
and distinct affections. 

The child in whom meningitis is approaching loses his accustomed viva- 
city and cheerfulness. He has a melancholy and subdued appearance, 
being quiet for a few minutes, and then fretful, without apparent cause. 
He can sometimes be amused by his playthings or companions for a brief 
period, when he turns from them with evident displeasure. Unexpected 
and loud noises and bright lights are evidently painful. If old enough to 



392 MENINGITIS, SIMPLE AND TUBERCULAR. 

describe his sensations, he complains of transient dizziness, and at other 
times of headache. His ill-humor, if his wishes are not immediately grati- 
fied, or if they are denied, is often scarcely endurable on the part of friends 
who are ignorant of the cause. There is great difference, however, in dif- 
ferent cases, as regards this symptom. Some are inclined to be taciturn 
and quiet, while others are almost constantly fretting. The appetite is 
capricious ; at one time it is pretty good, at another it is poor or even 
entirely lost. The patient may take a few mouthfuls of food, or, if an 
infant, nurse for a moment, when his hunger appears satisfied, and he will 
take nothing more. The bowels are regular or inclined to constipation. 
The pulse is natural, or it has times of acceleration, especially in the latter 
part of the day and towards the close of the premonitory stage. The dura- 
tion of this stage is very different in different cases. Upon an average it 
is perhaps about two weeks, but it is often longer. In tubercular menin- 
gitis the symptoms, both during the inflammation and previously, are apt 
to be complicated by those which arise from tubercles in other parts of the 
system. 

Unless the prodromic period is of short duration, the effect of imperfect 
nutrition is obvious before it closes. The flesh becomes soft and flabby, 
or there is actual emaciation, though generally slight. The patient loses 
his strength, becoming less able to stand or to walk, and more easily 
fatigued. Occasionally, especially in the simple form, premonitory symp- 
toms are absent, or are slight and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the tendency 
was towards refinement rather than simplicity in classification, divided 
meningitis into three stages, according to the symptoms, especially the 
pulse. Many subsequent writers, following Whytt's example, have recog- 
nized three stages, based not upon the anatomical characters of the disease, 
but upon the succession of symptoms. Such division of meningitis is in 
great measure arbitrary, since in one case the same symptom occurs at an 
earlier period than in another. 

When the premonitory stage has passed, and inflammation is developed, 
some of the symptoms which were previously present remain and are in- 
tensified, and other new and more characteristic symptoms appear. There 
are now fewer intervals of apparent improvement. The child is quiet, 
often lying with its eyes shut. If aroused, he has a wild expression of the 
face, and is irritated by attempts to engage his attention or amuse him. 
He rarely smiles, or takes his playthings, or he notices them for a moment, 
when he turns away with disgust. During sleep there is often at first a 
placid expression of countenance, but when aroused he has the aspect of 
real sickness ; the eyebrows are sometimes contracted, as if from head- 
ache ; the features wear a melancholy look, and are turned away to avoid 
the gaze of the observer or to shun the light. If the anterior fontanelle is 
open, it is observed to be prominent and pulsating forcibly. If conscious- 



SYMPTOMS. 393 

ness is not lost, and the patient is of sufficient age, he complains of head- 
ache, or of pain in some part of the body. The tongue is moist, and 
covered with a light fur ; the appetite is lost or poor ; there is seldom much 
thirst ; more or less nausea and constipation are present. As the inflam- 
mation continues, and usually within three or four days from its com- 
mencement, symptoms arise which dispel all doubts, if there were any, as 
to the nature of the disease. The vital powers are now evidently begin- 
ning to yield. The surface generally is more pallid, and there is the 
curious phenomenon of the sudden appearance, and, after some minutes, 
disappearance, of spots or patches, or even streaks of active congestion 
upon the face, forehead, or the ears. These, having a bright red color, 
contrast strongly with the general pallor. Ordinarily they are irregularly 
circular or oval, and from one inch to an inch and a half in diameter. A 
r^d spot or streak is also produced if the finger is pressed upon the surface 
or drawn forcibly across it. It continues a few minutes and then gradu- 
ally fades. Trousseau calls attention to this fact as a diagnostic sign. 

Another curious phenomenon is the variation in temperature. The face 
and limbs at one time feel quite cool, and after some minutes, without any 
excitement or other appreciable cause, the temperature rises, so that the 
surface is warm to the touch. 

Consciousness, -in severe cases, may be lost at an early period. On the 
other hand, I have known it in a case of moderate severity to remain, 
though partially obscured, till within twenty-four or thirty-six hours of 
death. The patient will usually open his mouth for drinks, which are 
placed to his lips, when there is no other evidence of intelligence, and 
when sight and hearing are evidently lost. 

The loss of the senses constitutes an interesting but melancholy feature 
of the disease. Among the first unequivocal symptoms, and frequently 
the very first, are such as pertain to the eye. This organ should be watched 
from day to day when the diagnosis is uncertain. Deviation from its nor- 
mal state affords evidence of meningitis. The pupils are seen to dilate or 
contract sluggishly by variations in the intensity of the light, or they are 
not of the same size with those of another individual to whom the same 
amount of light is admitted. Sometimes the first perceptible deviation 
from the normal state is an inequality in the size of the pupils ; while in 
others oscillation of the iris is observed. At a later stage, not generally 
till convulsions have occurred, the parallelism of the eyes is lost, and in 
most patients they have an upward direction. After effusion has occurred, 
the pupils are commonly dilated. As death approaches, the eyes become 
bleared, and a puriform secretion collects in the inner angle of the eye and 
between the eyelids. This secretion is not abundant, but it is sometimes 
sufficient to unite the lids. The sense of hearing is probably lost as soon, 
or nearly as soon, as that of sight, but the sense of touch continues longer. 
The tongue is covered with a moist fur, unless near the close of life, when 



394 MENINGITIS, SIMPLE AND TUBERCULAR. 

it is sometimes dry. The appetite is gradually lost, but often drinks are 
taken with apparent relish, even when there is no other evidence of con- 
sciousness. There are two symptoms pertaining to the digestive system 
which are rarely absent, and which possess great diagnostic value ; one is 
vomiting, the other constipation. In some patients, irritability of stomach 
begins at so early a period that it is really prodromic ; it is rarely absent. 
Barrier collected the records of eighty patients with meningitis, and in 
seventy-five of these this symptom was present. It is due to the intimate 
relation existing between the stomach and brain, through the ganglionic 
system of nerves. The vomiting occurs without effort, and usually at inter- 
vals, for several days. It is a sudden ejection of the contents of the sto- 
mach, apparently without preceding or subsequent nausea. It contrasts, 
therefore, with the vomiting due to an emetic, which is attended by dis- 
tressing symptoms. With some it occurs frequently, with others not more 
than two or three times daily. Commencing in the first stages of menin- 
gitis, or even prior to it, it occurs less often as the drowsiness becomes more 
profound, and finally ceases. Constipation is also present, usually from 
the commencement of the meningitis. It is one of the most constant and 
persistent symptoms, continuing through the entire sickness, unless relieved 
by medicine, or unless there is a coexisting diarrhoeal affection. Often, 
when diarrhoea precedes the meningitis, it ceases the moment the latter 
commences. The constipation in this disease is easily overcome by purga- 
tives. Several writers speak of retraction of the abdomen as a sign of 
meningitis. A hollow or sunken appearance of the abdomen, according 
to Golis, aids in distinguishing meningitis from fever. The anterior ab- 
dominal wall approaches the spine, so that the pulsations of the abdominal 
aorta are distinctly felt, liilliet and Barthez, who have rarely observed 
this retraction except in cerebral diseases, attribute it to the state of the 
intestines rather than to the action of the abdominal muscles. 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterwards accelerated. When the dis- 
ease has continued a few days, often not more than three or four, the pulse 
undergoes a marked change. It becomes slower, and at the same time, 
irregular. The irregularity usually consists in an intermittence of the pulse 
after each six or eight beats. Sometimes the force of the pulse varies, so 
that a feeble pulsation is succeeded by one of greater volume and strength. 
The decrease in the frequency of the pulse cannot fail to arrest attention. 
From 110 or 120 beats per minute in the first stage of the inflammation it 
often descends to a frequency even less than the normal adult pulse. At 
an advanced period, as death approaches, the pulse again becomes accele- 
rated and feeble. 

The change in respiration is as decided as that of the pulse. In the be- 
ginning of the meningitis respiration is sometimes moderately accelerated, 
but in other cases it is natural. When the disease has continued a few 



SYMPTOMS. 395 

days, the time usually varying from three or four to more than a week, a 
marked alteration occurs in the respiratory movements. Their rhythm, like 
that of the pulse, is disturbed. The breathing is irregular, intermittent, 
and accompanied by sighs. This change in pulse and respiration corre- 
sponds with the loss of consciousness, and shows that the brain is becoming 
seriously involved. 

When the pulse and respiration undergo the changes which have been 
described, another prominent and grave cerebral symptom is often present, 
namely, convulsions. Its occurrence diminishes greatly the prospect of a 
favorable issue. The severity and extent of the convulsive movements 
vary in different cases. They may be partial or general. Their duration 
is often brief, but they recur three or four times through the day. They are 
preceded by cephalalgia in those old enough to express their sensations, and 
often by drowsiness. Each convulsive attack ends in still greater drowsiness. 

With this group of symptoms another should be mentioned. I refer to 
the hydrocephalic cry. At intervals the patient, without being disturbed, 
and without any change in symptoms, utters a scream or sharp cry, and 
immediately relapses into his former state. This cry is more common in the 
commencement of the meningitis than subsequently, and in many it is absent 
or is not a marked symptom. The glandular system participates in the gen- 
eral loss or derangement of function. Tears are seldom shed, even when 
the child is much irritated, and the urinary secretion is diminished. The 
small amount of urine passed sustains an important relation to the pro- 
gress of the disease and the therapeutics. 

The patient usually lingers several days after the pulse and respiration 
are changed in the manner stated. The drowsiness becomes more pro- 
found, the vomiting ceases, as well as the convulsive attacks, and sensation 
and consciousness are entirely lost. But even in this state, if nutriment 
and stimulants are administered with regularity, the child often lives seve- 
ral days longer than the friends believed to be possible. At length increas- 
ing feebleness and rapidity of pulse and coldness of the face and limbs 
indicate the near approach of death, which occurs while in a state of coma. 

The symptoms described above are such as occur in ordinary cases of 
meningitis, and in the order which I have indicated. But he will be dis- 
appointed who expects that the above description will apply to all cases. 

Meningitis may be so violent and rapid that both the character and suc- 
cession of symptoms are different from those which have been stated. 
Thus, I have related the case of a girl, who, with no prodromic symptoms 
excepting occasional dizziness and slight headache, was taken sick on 
Thursday, had convulsions on Friday, and from this time continued either 
in convulsions or coma till her death on Monday. Again, even in cases of 
the usual duration and anatomical character, some of the most prominent 
symptoms upon which we rely for diagnosis may be lacking. The follow- 
ing was a case of this kind : — 



396 MENINGITIS, SIMPLE AND TUBERCULAR. 

Case — On the 5th of April, 1862, I was asked to see a boy two years 
and eight months old, of healthy parentage, and who, during the preced- 
ing year, had been in uniform good health, but previously had had two or 
three severe attacks of sickness. His head was unusually large, and 
whenever much indisposed he often had symptoms premonitory of convul- 
sions, which were always, however, prevented. 

One night, in the latter part of March, his parents noticed that his sleep 
was restless, but on the following clay he seemed entirely well, and the 
restlessness at night was attributed to a late and hearty supper. On suc- 
ceeding nights, however, he was restless, and, when questioned, complained 
of pain in the abdomen. In a few days he was observed to be drooping 
in the daytime, and his appetite w T as not quite so good as previously. He 
had continued in this way about a week when my first visit was made. 

The abdominal pain had at this time become more constant, but was 
never severe or accompanied by moaning. When asked where he felt sick, 
he placed his hand upon the epigastrium, pressure upon which was some- 
times tolerated, but at other times painful. The following symptoms were 
noted : tongue slightly furred, anorexia, thirst, constipation, scantiness of 
urine, no headache or unusual heat of head during any part of his sick- 
ness. He vomited at intervals from about the 7th to the 10th of April, 
when the irritability of stomach ceased, and there was no return of this 
symptom. 

About April 7th, the respiration was first observed to be irregular and 
sighing, and the pulse intermittent. These symptoms, so tardily devel- 
oped, were the first which indicated cerebral disease. He now lay most 
of the time in bed, with eyes closed, surface commonly pale, with occa- 
sional rose-colored spots or patches upon the cheek or forehead. The pupils 
responded to light in the usual manner till near the close of life, but bright 
lights were painful ; the last two or three days of his life the left pupil 
was more dilated than the right. He had no convulsions or any spasmodic 
movement, and was conscious till within a few hours of death ; the mother 
states that there was unequivocal evidence of his recognition of her on 
the last day of his life. He died April 17th, nearly three weeks after the 
commencement of the disease, and ten days after the commencement of 
symptoms which were distinctly referable to the brain. 

Autopsy Abdominal organs healthy, though epigastric pain had been 

so constant and prominent a symptom ; brain and its membranes some- 
what injected. The meninges covering the base of the brain from the 
most prominent part of the pons Varolii to the first pair of nerves pre- 
sented evidences of inflammation. There was such opacity of the pia 
mater in places, as to conceal the brain from view. The anterior and 
middle lobes of each hemisphere were glued together by fibrinous exuda- 
tion, and on the left side, along the fissure of Sylvius, was a thick deposit 
of the same character. The lateral ventricles contained about an ounce 
of clear serum, and about half an ounce escaped from the base of the brain. 
The foramen of Monro was considerably enlarged, and the brain-substance 
surrounding the lateral ventricles was somewhat softened, but not in a 
notable degree. 

In this case it is seen that the prominent symptom, and, indeed, almost 
the only marked symptom in the first stages of the disease, was pain in 
the abdomen, and yet the abdominal organs were healthy. At the very 
moment when it was highly important that a correct diagnosis should be 



DIAGNOSIS. 397 

made, the evidences of cerebral disease were lacking. This case is, there- 
fore, interesting on account of the variation in symptoms from those in 
the usual form of meningitis. There were no convulsions, and conscious- 
ness was retained as well as vision till near the close of life, and yet the 
lesions are such as are commonly present in meningeal inflammation. It 
is in such cases that a wrong diagnosis is apt to be made, to the injury of 
the patient and the reputation of the physician. 

Occasionally meningitis may continue so long as to almost justify its 
being called chronic, even when there is a large amount of exudation upon 
the pia mater. In the few cases which end favorably, the symptoms abate 
gradually. I shall describe more fully the termination in speaking of 
prognosis. 

Diagnosis It is of the utmost importance to diagnosticate meningitis 

in its first stages, since treatment, to be successful, must be commenced 
early. Certain writers describe at length the means of diagnosticating the 
simple from the tubercular form of the inflammation. Differential diag- 
nosis is often difficult, and sometimes impossible ; but it matters little, 
practically, whether the form of the disease is ascertained. On the other 
hand, it is very important, in order that the treatment be appropriate, to 
diagnosticate the premonitory or initial stage of meningitis from certain 
other affections not located within the cranium. Sometimes remittent or 
continued fever, or constitutional disturbances arising from irritation in 
the digestive system, simulate closely incipient meningeal disease, so that 
the greatest care and discrimination are required in order to make a cor- 
rect diagnosis. Within a comparatively recent period I have known, in 
three different instances, experienced physicians of this city mistake com- 
mencing meningitis for fevers, not aware of the serious error they had 
made till the inflammation had reached a stage from which recovery was 
impossible. In order to avoid error in the diagnosis in the premonitory 
or initial stage of meningitis, the physician should take time to observe 
the physiognomy, and note every symptom. More than one protracted 
visit is often required to remove doubt as to the exact pathological state. 

Meningitis is usually preceded and in its commencement accompanied 
by greater restlessness, fretfulness, intolerance of light, and greater varia- 
tion of symptoms than most other maladies. One familiar with the physi- 
ognomy of infancy and childhood, will discover in the features indication 
of greater suffering, of more serious sickness, than is commonly present in 
other maladies which simulate this. 

Sometimes the sudden disappearance of a chronic eruption upon the 
scalp will aid in the diagnosis. This is a sign of importance, taken in 
connection with the symptoms. Headache and vomiting, symptoms of 
early occurrence, should especially arrest attention, or, in absence of head- 
ache, pain of a neuralgic character in some other part. But we may re- 
peat that familiarity with the symptoms of meningitis will not protect from 



398 

error if the visits of the physician are hasty, and his examinations im- 
perfect. When the eyes become affected, the respiration and circulation 
irregular, and especially when convulsive attacks begin, diagnosis is easy. 
In fact, an incorrect diagnosis would then be unpardonable ; but, unfor- 
tunately, if proper treatment has not been commenced till this period, it 
will be of little service. 

Prognosis Meningitis is one of the most fatal maladies of early life. 

Whether the form is simple or tubercular, if the initial stage has passed 
without proper treatment, death may be considered inevitable. Tubercular 
meningitis, however early recognized, is rarely amenable to treatment. M. 
Guersant (Die. Med., t. xix, p. 403) believes that recovery from the first 
stage of this form of meningitis is possible. " In the second stage," says 
he, u I have not seen one child recover out of a hundred, and even those 
who seemed to have recovered have either sunk afterwards under a return 
of the same disease in its acute form, or have died of phthisis. As to 
patients in whom the disease has reached its third stage, I have never seen 
them improve even for a moment." The very few reported cases which 
resulted favorably may have been, as M. Guersant has intimated in the 
context, cases of the simple form. BilKet and Barthez believe that in a 
few instances tubercular meningitis has been cured in its first stage, but 
they state also that it is apt to return. 

The prognosis in simple meningitis is not so unfavorable, provided treat- 
ment is commenced at a sufficiently early period. It is now generally 
admitted that the simple form may not infrequently be averted, when 
threatening, and even arrested in its incipiency. In many such cases we 
cannot, from the nature of the disease, be certain that the diagnosis is 
correct. But when we see children relieved, who present precisely those 
premonitory and even initial symptoms which occur in meningitis, we 
must believe that at least some of them would have had the genuine dis- 
ease if not relieved by the measures employed. That recovery is possible 
from simple meningitis in its commencement, is also obvious from the fact 
that a few recover even in the second stage, when there can be no error 
of diagnosis. 

Although a considerable proportion of patients with epidemic cerebro- 
spinal meningitis recover, even when the symptoms have been most 
grave, I have known only two recoveries from sporadic meningitis when 
it had reached that stage, in which the functions of the brain and cranial 
nerves were impaired. One of these recovered with the permanent loss 
of sight, the other with the loss of hearing. Both seem to have ordinary 
intelligence. Another case has been communicated to me, in which the 
patient, a little girl, recovered completely, but for several months after 
the attack seemed nearly idiotic. 

Sometimes even in the second stage of meningitis, treatment properly 
employed is attended by amelioration of symptoms. Though such im- 



TREATMENT. 399 

provement may serve to encourage physician and friends, it should not be 
the basis of a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day, is not unusual in those who finally die. Thus, in an infant whose 
bowels were previously confined, I have known the pulse and respiration 
to become more regular and the symptoms generally improve; though only 
for a brief period, by the action of a purgative. Dr. Watson says of the 
advanced stages of this disease, it is " often attended with remissions, some- 
times sudden, and sometimes gradual, deceitful appearances of convales- 
cence. The child regains the use of its senses, recognizes those about him 
again, appears to his anxious parents to be recovering, but in a day or two 
it relapses into a state of deeper coma than before. And these fallacious 
symptoms of improvement may occur more than once." 

Most fatal cases of meningitis terminate between the third or fourth and 
the twentieth day, the duration varying according to the extent and inten- 
sity of the inflammation, and the vigor and age of the patient. But there 
are cases in which it may continue much longer. It is surprising some- 
times how long the patient lives, when the symptoms are such that death 
seems impending. Sensation and consciousness may be extinguished, 
convulsions occur at intervals, and the surface have acquired almost a 
cadaveric aspect, and yet the patient lives on. Rilliet and Barthez say : 
" Often have we inscribed upon our notes death imminent, and been 
astonished the next day to find still alive children to whom we had 
scarcely allowed two hours of life." The symptom which I have found to 
be the most reliable prognostic of the near approach of death, has been a 
pulse gradually becoming more frequent and feeble, though other symp- 
toms remain as before. This change in the pulse is usually very apparent 
during the last twenty-four hours of life. 

Treatment — Such remedial measures should be prescribed during the 
premonitory stage as are calculated to relieve the fretfulness or irritability 
of temper and quiet the action of the brain, and, at the same time, pro- 
duce a derivative effect from this organ. To this end the patient should 
be kept from all causes of excitement, and the bowels should be opened 
daily, if not naturally, by the use of proper medicines. A mustard foot- 
bath at night and occasionally through the day is useful, as it produces 
both a derivative and soothing effect. It will commonly produce a few 
hours' undisturbed rest, while all other measures except medicine fail. If 
dentition is taking place, and the gums are swollen, it has been the prac- 
tice to employ the gum lancet, and still is with some physicians, but I for 
one have discarded its use for this purpose. Restlessness from dentition 
or restlessness premonitory of meningitis, requires decided doses of bro- 
mide of potassium, which will relieve the symptoms more effectually than 
the lancet. Three grains should be given to a child of six months, and 
four grains to one of ten or twelve months, and repeated if necessary in 



400 

two to four hours. If symptoms indicate the near approach of meningitis, 
or its incipiency, the head should be kept cool by a cloth wrung out of 
cold water, and cantharidal collodion should be applied behind one or 
both ears, over a space one inch in diameter. 

Many children who are threatened with meningitis are scrofulous. They 
have already shown symptoms of tubercular disease. They are, perbaps, 
to a certain extent, emaciated, and may have been affected with a cough. 
The premonitory symptoms in these children indicate the approach of the 
tubercular form of meningitis, and a more sustaining course of treatment 
is required than in those who are robust. To such children cod-liver oil 
may be profitably given, three times daily, together with the syrup of the 
iodide of iron, and perhaps the bromide. They should also be taken into 
the open air, with proper precautions, and every hygienic measure should 
be employed which will be likely to invigorate the system without exciting 
the brain. 

Loss of blood is not, in general, required during the prodromic period 
nor in the disease. Those of a strumous cachexia, or those, whether 
strumous or not, who are under the age of two years, do not, unless in 
very rare instances, require depletion by leeches, much less by venesec- 
tion. There is one class of patients in whom the early loss of blood may 
doubtless, be of service, namely, those who in a state of robust health are 
suddenly seized with the inflammation. Leeches should then be applied 
to the head of the patient, if he is seen at an early period. 

Often, notwithstanding the measures employed, the patient grows worse, 
the symptoms become more continuous, others more alarming arise, and 
meningitis declares itself. Whatever the cause of the inflammation, and 
whatever modifications of treatment were required in the premonitory 
stage, on account of special indications, the purpose now is to subdue the 
inflammation by every resource in our art, which does not injure or too 
much prostrate the system. In former days calomel was largely employed 
as the main remedy in this disease, but when administered daily it- has a 
very depressing effect, and it is to be borne in mind that in meningitis the 
vital powers progressively fail on account of the loss of appetite, vomiting, 
etc. In tubercular meningitis depressing treatment is, of course, strongly 
contrainelicated, cases have occurred in which calomel was given at short 
intervals for several successive days, so as to produce a laxative effect, and 
though the meningitis seemed to be controlled, death occurred from ex- 
haustion, or from some intercurrent affection, the result of the exhaustion. 
Thus in one case related to the class by a distinguished professor in New 
York city, fatal gangrene of the mouth supervened from the mercurial 
treatment, after the meningeal inflammation had apparently subsided. 
Although calomel, during these last years, has been properly discarded as 
the main remedy, and its daily use rejected, nevertheless it is very useful 
as an occasional laxative in the more robust cases, if not given too near 



TREATMENT. 401 

the iodide of potassium, and it is especially indicated as a derivative from 
the head in children of four or five years, who, previously hearty and 
strong, have become suddenly affected with meningitis, as from exposure 
to the sun's rays or from an injury. But I repeat, that in my opinion, 
in ordinary cases, calomel should never be employed, except as an occa- 
sional laxative. 

The two remedies upon which we must chiefly rely are the iodide of po- 
tassium and the bromide of potassium, or sodium. While the bromide quiets 
the restlessness, prevents convulsions, and diminishes, there is reason to 
think, to a certain extent, the hyperemia, the iodide is useful as a sorbi- 
facient, and it probably has some control over the inflammation. The iodide 
or bromide can be given together or separately. 

The iodide should, like the bromide, be given early. If by a careful 
examination, the absence of any other local disease, or constitutional dis- 
ease, which might give rise to the symptoms is ascertained, and the symp- 
toms indicate the meningeal disease, the iodide should be immediately 
prescribed. Obscurity often hangs over meningitis at this early stage, 
but it is better to give the iodide, even if the diagnosis is wrong, and no 
inflammation has commenced, than to err on the other side, and withhold 
it in the initial period of the true disease, for it is not an injurious remedy 
like calomel, and to exert any marked curative effect, it should be given 
in the commencement of the inflammation. An infant of the age of six to 
twelve months should take two grains every two hours, and older children 
a proportionate dose. At the same time the bromide should be given in 
doses twice as large as that of the iodide, if the indications for its use 
are present, namely, headache, restlessness, and symptoms which threaten 
eclampsia. The bromide is a harmless remedy given often for a limited 
time. With the regular and continued use of the iodide and bromide, 
the quantity of urine is in most cases largely increased, and if the patient's 
condition do not soon begin to improve there is no remedy. 

If convulsions occur the bromide should be given every ten or fifteen 
minutes till they cease, or, if they are not controlled by the bromide, an 
injection, per rectum, of three to five grains of hydrate of chloral in a tea- 
spoonful of water should be used in addition. Compresses wrung out of 
cold water frequently applied to the head, or a bladder containing pounded 
ice, and separated by two or three thicknesses of muslin from the head, 
materially aids in reducing the meningeal hyperemia. 

In the first stage of simple meningitis the diet should be mild and in 
moderate quantity, but in the tubercular form it should from the first be 
of the most nourishing kind, consisting of beef-tea, milk-porridge, etc. 
At a more advanced stage in both forms of the malady the most nutritious 
diet should be allowed, but alcoholic stimulants should not be given unless 
near the close of life when the vital powers are failing. The apartment 
should be cool and quiet. 
26 



402 SPURIOUS HYDROCEPHALUS 



CHAPTER X. 

SPURIOUS HYDROCEPHALUS. 

The disease known as spurious hydrocephalus might with more propriety 
be called spurious meningitis. It received its appellation at the time when 
meningitis of early life was believed to be essentially a hydrocephalus, and 
was so called. Attention was first directed to this malady by London 
physicians of the last generation, particularly by Drs. Gooch, Abercrombie, 
and Marshall Hall, and little can be added to their description of its 
symptoms. 

Anatomical Characters This disease, though resembling menin- 
gitis in certain of its phenomena, is not in its nature inflammatory, nor is 
it primary. It is the result of some malady often chronic, but occasion- 
ally acute, which has produced exhaustion, especially of the nervous sys- 
tem. When it commences, there is usually more or less emaciation, and 
the symptoms of the primary disease are present. To this disease the 
lesions pertain which are found in other organs besides the brain. 

The state of the brain in spurious hydrocephalus is not the same in all 
cases. In some there is no appreciable anatomical alteration in this organ. 
There is no apparent difference, either in the meninges or the brain itself; 
from the condition which we often observe in those who have died of dis- 
eases which do not affect the cerebro-spinal system. In such cases the 
pathological state is simply deficient innervation, or if there is a structural 
change in the minute anatomy of the brain, pathologists have not yet dis- 
covered it. 

The following case, which occurred in the Child's Hospital of this city, 
is an example of this form of spurious hydrocephalus : — 

Case A female infant, six months old, died on the 24th day of April, 

1862, with the following history : It was wet-nursed, fleshy, and apparently 
well, till six days before death, when symptoms of gastro-intestinal inflam- 
mation were suddenly developed. The vomiting, especially, was severe, 
continuing forty-eight hours. When it ceased, drowsiness supervened, and 
continued till the close of life. The face during the four days of stupor 
was pallid and cool; eyes partly open, pupils sluggish, but of equal size ; 
bowels rather torpid ; anterior fontanelle depressed. When aroused, the 
infant noticed objects for a moment, and immediately relapsed into sleep ; 
pulse accelerated and not intermittent, the day before death numbering 
one hundred and fifty ; respiration accelerated, without sighing, number- 
ing on the same day thirty. There were no convulsions, and death occurred 
quietly. The brain weighed twenty and a half ounces, and its appearance 
was perfectly healthy, both as regards consistence and vascularity. The 



SYMPTOMS. 403 

amount of cerebro-spinal fluid in the ventricles and at the base of the brain 
was not notably increased. The stomach, small and large intestines, were 
vascular in streaks and patches. 

In this case the cerebral symptoms were obviously due to exhaustion 
occurring at an early period, in consequence of the severity of the gastro- 
intestinal affection. 

In a majority of cases, however, of spurious hydrocephalus, according to 
my observation, there is an anatomical alteration in the state of the brain 
and meninges. This consists in passive congestion of the veins, often with 
transudation of serum. At the same time the cranial sinuses are congested, 
and are found at the post-mortem examination to contain larger and more 
numerous clots than are present in those who die of diseases which do not 
affect the encephalon. Cases might be cited as examples. The cause of 
this congestion and effusion is, in great measure, feebleness of the circula- 
tion due to the general exhaustion of the patient. But there is another 
cause. In protracted diseases, especially those of a diarrhoeal character, 
there is more or less wasting of the brain as well as of other parts. This 
naturally, by way of compensation, gives rise to congestion of the cerebral 
and meningeal veins and capillaries and to transudation of serum. 

The transudation commonly occurs in this malady over the superior sur- 
face of the brain and in the subarachnoidal space, perhaps also more or 
less in the lateral ventricles. So common is it in the last stage of infantile 
entero-colitis, the summer epidemic of the cities, that this stage, which is 
really spurious hydrocephalus, has been called the stage of effusion. I shall 
relate in another place examples which show the anatomical characters of 
this intestinal disease. 

Symptoms Spurious hydrocephalus most frequently results from pro- 
tracted diarrhoeal complaints. It may, however, result from any disease 
which is attended by great prostration. As it ordinarily occurs, the patient 
has for days or weeks been gradually losing flesh and strength. Finally 
drowsiness supervenes, or before the drowsiness there is sometimes a period 
of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first he says : " The infant becomes irritable, restless, and feverish ; the face 
flushed, the surface hot, and the pulse frequent ; there is an undue sensi- 
tiveness of the nerves of feeling, and the little patient starts on being 
touched, or from any sudden noise ; there are sighing and moaning during 
sleep, and screaming ; the bowels are flatulent and loose, and the evacua- 
tions are mucous and disordered." The second stage he describes as that 
of torpor. The first stage often, however, does not present those promi- 
nent symptoms which have been described by Dr. Hall, and this stage 
may even be absent, or not appreciable, especially in young infants. 

Whether or not commencing with the stage of irritability, the disease, 
if not checked, gradually increases. The child soon becomes drowsy. He 



404 SPURIOUS HYDROCEPHALUS. 

may be aroused for a moment, but, unless constantly disturbed, immedi- 
ately relapses into sleep. He is sometimes fretful when aroused, but in 
other instances is quite indifferent, observing without apparent interest 
objects employed for the purpose of amusing him. Often there are indi- 
cations of cerebral pain or distress, as contraction of the eyebrows, etc., 
but many of those affected are too young to make known their sensations. 
Convulsions sometimes occur towards the close of life, but they are not so 
common in this disease as in meningitis. When they do occur, they are 
generally partial and often slight. The pulse is accelerated in most patients 
prior to and in the commencement of spurious hydrocephalus. As the 
disease advances it becomes irregular and intermittent, and towards the 
close of life it is progressively more frequent and feeble. The respiration 
at first is not much disturbed, but at length it becomes irregular, like the 
pulse. It is feeble and accompanied by sighs. Occasionally there is slight 
cough. The eyelids are partly open, the pupils no longer respond to light, 
and in advanced cases they have a bleared appearance. The diarrhoea, 
which in most instances precedes and causes this malady, continues till the 
stage of stupor arrives, when the evacuations become less frequent or cease 
altogether. In infants the stools are frequently green, in older children 
brown and sometimes slimy. The febrile heat of surface, which preceded 
the disease and was present in its commencement, disappears ; the face and 
hands become cool, the features pallid, and the anterior fontanelle, if open, 
is depressed. Death finally occurs in a state of coma, or, if the disease is 
recognized and proper remedial measures employed, the result may be 
favorable, even when the symptoms are such that if meningeal inflamma- 
tion were the disease we would consider the case necessarily fatal. 

The following case is an example of spurious meningitis as we often 
meet it in practice : — 

Case On the 13th day of March, 1859, I was asked to see a male 

child twenty-two months old, the records of whose case are as follows : 

" Was well till about three weeks ago, since which time he has had 
diarrhoea, with febrile symptoms; pulse 162, respiration 52; has a slight 
cough, with a few mucous rales ; resonance on percussion of chest good ; 
is somewhat emaciated, and appears languid ; tongue moist and slightly 
furred. Has all the incisor and three anterior molar teeth, and the gum 
is swollen over the remaining anterior molar and two canine teeth." 

From the 14th to the 18th there was no material alteration in his symp- 
toms, with the exception that the diarrhoea was partially restrained by 
Dover's powder in one and a half grain doses. On these five days the 
stools numbered daily from one to six. The pulse was uniformly frequent, 
varying from 124 to 156, and the respiration on two days, when its fre- 
quency was ascertained, numbered 56 and 46. 

"March 19th, pulse 124; has become drowsy since yesterday, and when 
aroused is fretful. Omit Dover's powder. Treatment, cold applications 
to the head, mustard pediluvia. 

" Evening, pulse 136; eyes constantly closed and head reclining; sur- 
face generally warm ; tongue dry and furred ; vomited at first, but has not 



SYMPTOMS. 405 

in three or four days. Apply cantharidal collodion behind each ear, and 
continue the local treatment. 

" 20th, pulse 130 ; is constantly sleeping, and when aroused is very fret- 
ful and soon relapses into sleep ; no unnatural heat of head, and no dejec- 
tion since yesterday. Treatment, a dose of castor oil, nourishing diet. 

a 21st, drowsiness as before ; cheeks sometimes flushed, sometimes pale; 
pupils sensitive to light ; margins of eyelids covered with secretion. The 
bowels have been opened by the oil." 

On the 22d and 23d there was no material change in the symptoms. He 
was constantly sleeping, except for a moment when shaken. More active 
stimulation was now employed. Brandy was prescribed, to be given every 
two hours ; beef tea and milk porridge frequently. 

On the following day, the 24th, he was more fretful, and less drowsy. 
Brandy and beef tea were continued. 

On the 25th, with the same treatment, there was still further improve- 
ment ; drowsiness nearly gone and less fretfulness than yesterday ; rolls 
the head occasionally and does not appear to see distinctly ; has a slight 
cough; stools nearly regular; pulse 100; respiration natural; surface warm, 
and no unnatural heat of head. The same treatment was continued, and 
he rapidly and fully recovered. 

This case is intesting on account of the long duration of marked drow- 
siness, which continued five days, and yet the patient recovered entirely 
in the space of two or three days under the use of brandy and beef tea. 

In May, 1860, I was called to treat a very similar case. A child, 
twenty months old, had diarrhoea for two weeks, the stools being of a 
dark-brown color, thin and offensive. He was at first very irritable. The 
pulse was constantly above 130, and the respiration was correspondingly 
increased. The stage of drowsiness finally supervened, and for two days 
he was constantly asleep unless aroused by being shaken. During the 
somnolent stage the pulse numbered 140, respiration 36. The face and 
extremities were cool and he finally had a slight convulsion. By stimu- 
lants and nutritious diet he began immediately to improve, and was soon 
out of danger. 

In the following case the result was unfavorable. This case is interest- 
ing on account of the anatomical characters of the disease as disclosed by 
the post-mortem examination. It is an example of that large class of 
cases in which spurious hydrocephalus is associated with congestion of the 
cerebral vessels and serous effusion. It is exceptional, however, as regards 
the long duration of drowsiness. Ordinarily, protracted diarrhoeal maladies 
which end in passive congestion and effusion, terminate fatally in three 
or four days after the drowsy period arrives. 

Case — "Dec. 13th, 1861, called to-day to a German infant eighteen 
months old. It has had diarrhoea four weeks without regular and proper 
medical attendance ; stools from the first brown and thin ; during the last 
eight or nine days he has been drowsy ; when aroused, opens his eyes and is 
very fretful, but immediately the upper eyelids gradually droop, and, unless 
disturbed, he remains asleep with his eyes partially open ; forehead warm, 
face cool and pallid, and limbs also rather cool ; pulse 164, respiration 32 ; 



406 SPURIOUS HYDROCEPHALUS. 

has had a slight cough about one week, and slight dulness on percussion 
over the left infra-scapular region ; depression of infra-mammary region 
on inspiration. Treatment : Ammon. carbonat. gr. 1 every two hours ; 
nourishing diet. 

" Dec. 20th, has continued drowsy since the last record ; pupils mode- 
rately dilated; a thick secretion between eyelids ; right pupil considerably 
larger than the left ; vision apparently lost during the three last days ; 
pulse over 140; respiration 44 per minute, accompanied by sighing since 
the 18th; moans much when awake; rolls the head frequently; during 
the last six days the surface back of the ears has been constantly sore by 
vesication ; takes the most nutritious diet, with brandy. The dejections 
remain thin and brown, and number three or four daily. 

"From this date the diarrhoea continued, except as it was restrained by 
vegetable astringents. The pulse continued frequent, and a slight cough 
remained. There was on the 21st and 2 2d partial abatement of the 
drowsiness, but on the 23d it was greater than ever. The body was some- 
what reduced at the commencement of the cerebral symptoms, but it was 
now considerably emaciated. The prostration increased daily, and the 
hands were observed to tremble. The face and hands became more cold, 
while the head was warm. On the 24th partial convulsions occurred, fol- 
lowed by coma and death. 

" The cerebral veins and sinuses were generally congested, except in the 
anterior portion of the brain, where the appearance was normal. Between 
the brain and its membranous covering, chiefly at the vertex and the base, 
was an effusion of clear serum. The whole amount of this fluid was esti- 
mated at two ounces. On slicing the brain, numerous ' puncta vasculosa' 
were seen, both in the gray and white portions. With the exception of the 
congestion, the substance of the brain presented its normal appearance. 
No inflammatory lesions were present. We were not permitted to examine 
the condition of the intestines." 

Diagnosis The only disease with which spurious hydrocephalus is 

liable to be confounded is meningitis. The points of differential diagnosis 
are the history of the case, especially the antecedent diarrhoea or other 
exhausting ailment, evidence of prostration when the cerebral malady com- 
menced, depression of the anterior fontanelle in young children, and the 
cool face and extremities. 

Prognosis If the pathological state of the brain is simple exhaustion, 

the disease can often be arrested by judicious treatment. If an incorrect 
diagnosis be made, and the treatment employed is that appropriate for 
meningitis, which it so closely simulates, death is almost inevitable. If 
transudation of serum has occurred, unless slight, the result is apt to be 
unfavorable, whatever may be the treatment. This disease in childhood 
is more easily managed than in infancy, but is less frequent. The prog- 
nosis is better in the cool months than during the heat of summer. It is 
more favorable if the child is over than if under the age of one year. The 
occurrence of an irregular and intermittent pulse, of respiration accom- 
panied by sighs, of inequality in the pupils or their sluggish movements, 
with increasing stupor, indicates an unfavorable issue. The cure of the 
primary disease, with the pulse and respiration still natural, or accelerated, 



ECLAMPSIA. 407 

without change of rhythm, pupils sensitive to light, drowsiness from which 
the patient is easily aroused to a state of entire consciousness, render 
recovery probable, with proper medication and alimentation. 

Treatment The indications of treatment are twofold : first, to remove 

the primary pathological state which is the cause of the spurious hydro- 
cephalus ; and, secondly, to cure the latter. The first is important, since 
the successful treatment of a disease requires the removal of the cause. 
The measures employed for this purpose are pointed out in our descrip- 
tion of the diarrhoeal and other maladies which produce spurious hydro- 
cephalus. 

We may here say that as spurious hydrocephalus is due in a very large 
proportion of cases to the exhausting effect of long-continued diarrhoea, 
astringents, especially of subnitrate of bismuth, and alkalies are required 
in . a majority of cases in the stage of irritability, and sometimes also 
opiates. 

Active sustaining measures are indicated. Exhausted nervous power, 
as well as passive cerebral congestion, requires this. The diet should be 
highly nutritious, comprising such substances as milk and animal broths, 
and should be given frequently. Brandy is required at short intervals. 
Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, 
properly diluted, as a quick and active stimulant. Six or eight drops may 
be given in sweetened water to a child one year old, and repeated every 
hour in cases of urgency. If, by proper treatment of the cause, and by 
the use of stimulants and nutritious food, the patient does not within a 
few hours become less stupid and more conscious, there is that degree of 
nervous exhaustion or of serous transudation from the engorged cerebral 
veins which will render death probable. In some cases it is proper to 
produce moderate vesication behind the ears. 



CHAPTER XI 

ECLAMPSIA. 



The term eclampsia is used in a more restricted sense by some writers 
than by others. It is used in the following pages to designate those con- 
vulsive seizures, clonic in their character, sometimes general, sometimes 
partial, which affect the external muscles. Eclampsia is therefore synony- 
mous with clonic convulsions. It consists in a rapid, forcible, and invol- 
untary muscular contraction, alternating with relaxation. It is distinguished 
from chorea in the fact that the latter is a more permanent state, and is 



408 ECLAMPSIA. 

characterized by muscular movements which are partially under the con- 
trol of the will, and are not so violent. 

Eclampsia occurs in a great variety of diseases, some of which are 
located in the cerebro-spinal system, some in other parts of the body, and 
some are constitutional. It may also be produced by temporary derange- 
ments of system, not sufficiently severe to be considered diseases, and by 
powerful mental impressions, those of an emotional nature, affecting the 
delicate and sensitive nervous system of the child. Pathologists recognize 
three distinct forms of eclampsia. The term essential or idiopathic is used 
when the convulsions have no appreciable anatomical character, that is, 
when there is no apparent pathological state in the brain or elsewhere, 
w T hich gives rise to the attack. For example, if a child dies in convul- 
sions from fright, and all the organs, including the brain, are found in 
their normal state, the eclampsia is called idiopathic or essential. If the 
cause is disease of the brain or spinal cord, it is termed symptomatic. If 
it arises from disease elsewhere, as from pneumonia, the term sympathetic 
is employed. This is in the main a good division, but eclampsia may be 
at the same time sympathetic and symptomatic, as when it occurs in con- 
sequence of congestion of brain, which is induced by severe and frequent 
paroxysms of hooping-cough. 

Causes Eclampsia occurs at any period, of infancy and childhood, 

but it is much more rare after the period of six or seven years than pre- 
viously. Some children are more liable to it than others. It is produced 
in one by an agency which in another has no appreciable effect. There 
are some, generally those of an impressible nervous system, who are seized 
with convulsions whenever there is any slight derangement in the diges- 
tive or other organs. Eclampsia is frequent in certain families. Thus, 
Bouchut mentions a family of ten persons, all of whom had convulsions 
in their infancy. One of them married, and had ten children, all of 
which, with one exception, had convulsions. 

The exciting causes of eclampsia are too numerous to be mentioned in 
full. It is a symptom in nearly all cerebral diseases. It is produced in 
the nursling by changes in the milk with which it is nourished. These 
changes are usually due to violent emotions of the mother, as anger, fright, 
and grief, to the use of acescent or indigestible food, or to derangement, 
temporary or permanent, in her health. Thus, in a case related to me, the 
catamenia so affected the milk that the infant was seized with eclampsia at 
each monthly period. In childhood the most common cause of clonic con- 
vulsions is the presence of some irritant in the prima? viae. All kinds of 
fruit, even the mildest, may produce eclampsia, especially when eaten un- 
ripe or taken in undue quantity. I have known an infant to be seized with 
convulsions from eating strawberries, which parents usually regard as 
harmless, and one of the most violent and protracted cases of eclampsia 
which I have witnessed, occurred in a child over the age of six years, 



PREMONITORY STAGE. 409 

from swallowing, in considerable quantity, the parenchymatous portion of 
an orange. Constipation, worms, dysentery, intussusception, and painful 
dentition are also causes which are located in the digestive apparatus. 
Inflammation in some part of the respiratory apparatus is a not infrequent 
cause. Thus eclampsia occurs occasionally in severe coryza, in consequence, 
according to some, of the proximity of the inflamed surface to the brain, 
and the consequent afflux of blood to this organ. It is a common compli- 
cation also of pertussis and pneumonia. It occurs often at the commence- 
ment of two of the eruptive fevers, namely, smallpox and scarlet fever, 
and in the course of the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut re- 
lates the case of a girl, five years old, who was corrected before her com- 
panions, and was so affected by anger that convulsions ensued. Residence 
in close and overheated apartments, or in streets where the air is loaded 
with offensive vapors and is stifling, is a predisposing cause, so that there 
is a larger proportion of deaths from convulsions in the cities than in the 
country. 

In young children, burns, even when not very severe, are apt to termi- 
nate suddenly in eclampsia, succeeded by coma and death. Urinary cal- 
culi, both renal and vesical, frequently produce the same result. 

Such are the more common causes of eclampsia. It is seen that they 
are of two kinds, predisposing and exciting. An excitable or impressible 
state of the nervous system constitutes the chief predisposition to the 
disease. Plethora, or its opposite state, anaemia, increases the liability to 
an attack. 

Premonitory Stage In the majority of cases there are prodromic 

symptoms, which the experienced and careful physician can detect, so as 
to forewarn friends. The child is perhaps more or less drowsy, and, when 
disturbed, fretful. The eyes often have a wild or unnatural appearance ; 
occasionally they are fixed for a moment on an object, and yet apparently 
without noticing it. The sleep is disturbed ; in some there is unusual 
heat of head, and, if old enough, complaint of headache. At times, es- 
pecially if the primary disease is febrile or inflammatory, there is inco- 
herence of thought or expression, or even actual delirium. In some chil- 
dren, when eclampsia is threatening, the thumbs are seen to be carried 
often across the palms. I have observed this especially during the 
convulsive cough of pertussis. A very important prognostic symptom is 
sudden starting, or twitching of the limbs. This shows that the nervous 
system is profoundly impressed, and but slight additional excitation is 
required to develop eclampsia. This sudden starting not infrequently 
precedes the attack several hours, and gives sufficient forewarning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their 
visits, in many instances do not notice them. The symptoms which pre- 



410 ECLAMPSIA. 

cede symptomatic and sympathetic eclampsia are, moreover, blended with 
those of the primary affection, and hence another reason why they are 
apt to be overlooked. When the convulsions are about to commence, the 
child generally lies quiet ; the eyes are open and fixed. If spoken to or 
shaken, he takes no notice, and does not speak. The direction of the 
eyes is then changed ; often they are turned up ; sometimes there is stra- 
bismus. The face may be pale or flushed, and sometimes, especially in 
cerebral diseases, the features present patches or streaks of a flushed ap- 
pearance, while around them the natural color is preserved. Immediately 
before the spasmodic movements the child occasionally utters a piercing 
scream, which is probably involuntary, though it seems like a supplication 
for help. The duration of the prodromic stage is very different in different 
cases. It may last from a few minutes to several hours, or even more 
than a day. 

Symptoms — Eclampsia is general or partial. If general, the muscles 
of the face, eyes, eyelids, and of all the limbs, are in a state of rapid 
involuntary contraction, alternating with relaxation. The features lose 
their natural expression and are distorted ; the mouth is drawn out of 
shape, often to one side, by the violent muscular action ; the teeth are 
pressed together by tonic contraction of the masseters, and may be vio- 
lently struck together, so as to lacerate the tongue, if it protrude, or are 
ground upon each other. Unless the attack is of short duration, frothy 
saliva, perhaps tinged with blood from the injured tongue, collects between 
the lips. The eyelids are usually open, and in severe cases the eyes are 
turned so that the pupils are lost under the upper eyelids, or the muscles 
of the eyes are involved in the spasmodic movements, so that the eyeballs 
are forcibly drawn from side to side. Occasionally strabismus occurs. 
While the features are thus distorted, the head is strongly retracted or is 
turned to one side ; the forearms are alternately pronated and supinated ; 
the thumbs and fingers are convulsively flexed, so that the thumbs lie 
across the palms and are covered by the fingers ; the great toe is adducted, 
the other toes flexed ; and the toes, as well as legs, participate more or less 
in the spasmodic movements. 

In general convulsions, consciousness is usually lost. The head is hot 
previously to and during the attack — at least in the first part of it — and 
the face flushed. In exceptional cases, especially in sympathetic eclampsia, 
the head is cool and the face pale. The pulse is somewhat accelerated, as 
w T ell as the respiration, and the latter is rendered irregular if the respira- 
tory muscles, especially those of the larynx, are involved, as they generally 
are. The sphincters are relaxed during the convulsive attack, so that in 
many cases the urine and stools are passed involuntarily. 

Partial eclampsia is more common than the general form ; it occurs in 
the muscles of the face, including those of the eye, of the face and of one 
or both upper extremities, or of the face and the extremities on one side. 



SYMPTOMS. 411 

The spasmodic movements may be even limited to the muscles of the eye, 
and they often occur only in these muscles and those of the face. Rarely, 
if ever, does eclampsia afFect the legs without affecting also the muscles ot 
the arms and face. In partial convulsive attacks, sensation and conscious- 
ness are in some patients not entirely lost, but in others they are not mani- 
fested if present. 

The duration of an attack of eclampsia varies in different cases from a 
few minutes to several hours, with an average of not not more than from 
five to fifteen minutes. The movements do not often continue longer than 
three or four hours in the severest cases. They are sometimes said to 
last a much longer time, even for days, but there are in these cases inter- 
missions. Violent attacks are usually short. 

When the convulsion ends favorably, the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep in- 
spiration, after which it lies quiet, and the respiration remains regular or 
moderately accelerated. Some fully recover in a few minutes if the eclamp- 
sia has been light and the cause transient, and seem to experience no in- 
convenience except soreness of the muscles and fatigue. Others soon re- 
cover consciousness, and their temperature, respiration, and circulation 
become natural, but they remain dull for a time, their minds are bewildered, 
and they are perhaps unable to speak. In a few hours these untoward 
symptoms pass away. In essential, and in a large proportion of cases ot 
sympathetic eclampsia, if properly treated, and if the cause is recognized 
and removed, there is no recurrence of the convulsion ; with others it is 
different. In many cases, especially of symptomatic eclampsia and ot 
sympathetic, in which the cause is grave and persistent, the convulsions 
return after a variable period of a few minutes or a few hours. Six or 
eight or more convulsions may occur within twenty-four hours. Rarely 
they occur several times daily for several consecutive days, but severe con- 
vulsions, repeated at short intervals for twenty-four or forty-eight hours, 
usually end in fatal congestion of the brain or serous effusion. I once 
attended an infant about six months old, who had from four to twelve con- 
vulsions daily for eleven days, caused probably by a vesical calculus, as 
there was dysuria, and, at times, bloody urine. Some days after the con- 
vulsions were controlled, while we were deferring exploration of the blad- 
der, death occurred suddenly, and the autopsy was not permitted. This 
case will be detailed elsewhere. Bouchut has witnessed a case of hooping- 
cough in which there were daily convulsions for eighteen days. 

In severe eclampsia, the respiration is so embarrassed and circulation 
so retarded that congestion of various organs results. This passive con- 
gestion in the respiratory organs is indicated by moist rales in the larynx 
and bronchial tubes ; occurring in the brain, it is indicated by profound 
stupor. It has already been stated that death may occur from the cere- 
bral congestion, which, continuing, is apt to end in effusion of serum or 



412 ECLAMPSIA. 

extravasation of blood. In these cases the convulsive movements cease, 
but there is no return of consciousness. The child lies quiet, as if in sleep, 
with pupils not readily acted upon by light, and often somewhat dilated ; 
gradually the limbs grow cool and the pulse feeble, and fatal coma super- 
venes. 

Death does not ordinarily occur from one attack. There are several at 
intervals, during which the stupor is gradually becoming more and more 
profound, till, finally, there is total loss of consciousness and sensation. 
This is the most frequent mode of death, namely, from coma. Apnoea 
may occur in the first attack, ending life abruptly and unexpectedly, but 
in other instances it does not result till after several seizures, when, at 
length, one more violent than the others interrupts the respiratory function 
and causes death. 

Occasionally, when life is preserved, there is some permanent ill effect 
of eclampsia. Bouchut says: " The origin of certain permanent contrac- 
tions which bring on deviation of the head or of other parts, retraction of 
the limbs, paralysis, etc., must be referred to the convulsions of the mus- 
cles. I have seen several children in whom torticollis had no other 
cause. The drooping of the upper eyelid, strabismus, irregularity of the 
mouth, severe contractions of the limbs, often depend on this influence. 
These accidents are consequences of essential as well as of symptomatic 
convulsions." 

Anatomical Characters The morbid anatomy pertaining to 

eclampsia is in most cases twofold : first, the pathological states which 
precede and cause the convulsive movements ; secondly, those which result 
from them. We have seen that in sympathetic eclampsia the diseases 
which sustain a causative relation are very numerous ; some are constitu- 
tional, others local, and the latter may have their seat in almost any part 
of the economy, distinct from the cerebro-spinal axis. In some cases of 
sympathetic eclampsia the immediate cause is too active a circulation, a 
state of hyperemia of the cerebral vessels. 

It has already been stated that this hypersemia may be diagnosticated 
in young infants in whom the anterior fontanelle is open. Such infants, 
seized with acute inflammation of the mucous surfaces or of the lungs, 
often present a full and rapid pulse and a convex and forcibly pulsating 
fontanelle before the eclampsia begins. In other cases of sympathetic 
eclampsia the primary disease induces passive congestion of the brain, 
and this in turn gives rise to convulsions. Eclampsia occurring during 
the paroxysms of hooping-cough affords an example. In the contagious 
diseases, as smallpox and scarlet fever, eclampsia is doubtless often pro- 
duced by the direct action of the specific virus on the cerebro-spinal system. 
Therefore, in a considerable proportion of cases of eclampsia due to diseases 
not located in the cerebro-spinal system — in other words, of sympathetic 
eclampsia — the primary disease induces a pathological state of the cerebral 



DIAGNOSIS. 413 

vessels or of the blood which circulates through them, which state imme- 
diately precedes and accompanies the convulsions. 

In other cases of sympathetic eclampsia the convulsive movements are 
produced by the primary disease, acting directly on the nervous system, 
through the medium of the nerves, without causing any appreciable altera- 
tion in the state of the cerebro-spinal axis. Thus Barrier relates three 
fatal cases of convulsions occurring in pneumonia, in none of which was 
there anything abnormal in the condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia differs in dif- 
ferent cases, since convulsions occur in almost every disease of the brain 
and its membranes. The immediate cause of this form of eclampsia may 
be active or passive cerebral congestion, with or without effusion ; it may 
be compression of the brain from various causes ; it may be a deficiency 
as well as excess of the cerebro-spinal fluid. 

In essential eclampsia the cause sometimes produces congestion of the 
brain prior to the convulsive seizure. In other cases, as when convulsions 
occur immediately from the effect of anger or fright, there is no appre- 
ciable change in the state of the nervous centres previously to the attack. 

Again, eclampsia, especially when severe and protracted, and when 
occurring in successive attacks, may be the cause of certain lesions. It 
produces congestion of the brain and membranes, and perhaps of the spinal 
cord. Sometimes, if the congestion is great, there is also escape of serum 
from the distended capillaries, and the fibrin in the larger vessels, as the 
sinuses may coagulate. 

The congestion resulting from eclampsia may give rise to extravasation 
of blood and the formation of a clot. If this accident occur, there is often 
paralysis affecting more or less of one side, permanent or gradually dis- 
appearing. 

It may be difficult to decide whether the cerebral congestion precedes 
the eclampsia or is its result ; but in those cases in which it precedes and 
operates as a cause, it is no doubt increased during the convulsive period. 
The spasmodic muscular action, by rendering respiration irregular and 
imperfect, also leads to congestion of the lungs and sometimes of the 
abdominal organs. 

Diagnosis The only disease for which there is danger of mistaking 

eclampsia is epilepsy. M. Ozanam mentions the following means of dis- 
tinguishing the two : " Eclampsia differs from epilepsy in the frequent 
occurrence of prodromic symptoms ; the clonic form of the convulsions, the 
rare appearance of froth in the mouth, the absence of a hideous livid 
aspect of the countenance, the spasmodic and sobbing character of the 
respiration, frequency of the pulse, and a state of quiet without snoring 
which succeeds an attack." In the young child, however, the above points 
of distinction are not reliable as a means of differential diagnosis. Some 
patients, who seem to have genuine attacks of eclampsia in infancy and 



414 ECLAMPSIA. 

childhood, prove to be epileptic in subsequent years. The usual period of 
eclampsia is prior to the age of five years. If convulsions occur after this 
age without apparent exciting cause, or from trifling causes, in those who 
have not before had eclampsia, the disease is probably epilepsy ; if prior to 
the age of six years, and especially of three or four, they are in the vast 
majority of cases the convulsions of eclampsia. 

It is often difficult to ascertain the form of eclampsia, whether essential, 
symptomatic, or sympathetic — in other words, to determine the cause — 
till after the convulsions cease. This is especially true when, as is fre- 
quently the case, the physician is not summoned till the convulsive move- 
ments begin, and it is necessary that he should act promptly, with but 
little knowledge of the child's previous history. If there is an obvious 
antecedent disease, as hooping-cough or meningitis, the cause is apparent ; 
but if the previous health have been good, or but slightly disturbed, it may 
be necessary to make more than one visit or examination in order to ascer- 
tain the seat and character of the cause. In the majority of cases of con- 
vulsions occurring suddenly in a state of previous good health, the cause 
is seated in the intestines, but sudden and unexpected attacks may be due 
to the commencement of some inflammatory affection, as pneumonia, or 
of a febrile disease, as smallpox. Unless the eclampsia is speedily fatal, 
the physician, if he examine carefully, will, in most cases, soon be able to 
ascertain the nature of the cause, and diagnosticate the form of the 
disease. 

Prognosis Symptomatic eclampsia is always serious. If it occurs in 

the course of a cerebral disease, it indicates the approach of death, but if 
at the commencement, some may recover. The recurrence of it, what- 
ever the cerebral disease, is an almost certain prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the 
severity of the attack, and on the age, strength, and previous condition of 
the child. If there are predisposing or co-operating causes, as a nervous 
or excitable temperament, or dentition, the prognosis is less favorable than 
when such causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according to the 
nature of the primary disease, and often according to the stage of that 
disease. If convulsions occur at the commencement of an eruptive fever, 
they generally subside without untoward symptoms, and the fever pursues 
a favorable course. Eclampsia, after the appearance of the eruption, is 
premonitory of a fatal result. I have not yet known a patient with 
scarlet fever recover who had convulsions after the rash had covered the 
body, and experienced physicians of this city tell me that their observa- 
tions correspond with mine. Dr. J. F. Meigs, however, relates one favor- 
able case. If the cause of the eclampsia be located in or upon the mucous 
surfaces, a majority recover with judicious treatment. In convulsions 
consequent on pneumonia or a burn, more die than recover. 



TREATMENT. 415 

The prognosis in eclampsia is more favorable if the parallelism of the 
eyes is retained, the pupils remain sensitive to light, and consciousness 
soon returns. A fatal termination may be predicted, if, after the convul- 
sion, the child remains stupid, without any evidence of returning con- 
sciousness, and the pupils do not respond to light. 

Treatment Fortunately, inasmuch as the physician is often required 

to treat eclampsia in ignorance of the cause, the same measures are de- 
manded, to a considerable extent, in all cases, whether the form be essen- 
tial, symptomatic, or sympathetic. As early as possible in the attack the 
feet should be placed in hot water to which mustard is added, or, if it can 
be procured with little delay, a general warm bath may be used in place. 
This has a soothing effect upon the nervous system and promotes muscular 
relaxation, while it also produces derivation of blood from the cerebro- 
spinal axis. It is, therefore, useful, especially in those cases in which 
active or passive congestion precedes the eclampsia ; it is also useful as a 
preventive of passive congestion and consequent oedema of the brain, 
lungs, and other organs, which are the most serious results of eclampsia. 
It should be continued from six to fifteen or twenty minutes, according to 
the severity and duration of the attack ; at the same time cold applica- 
tions should be made to the head, until its temperature, which is usually 
increased, is reduced. The application of a cloth, frequently wrung out 
of cold water, is the most convenient and ready mode of employing this 
agent. Cold thus employed acts promptly in contracting the vessels of 
the brain and meninges, and diminishing the cerebral congestion. It 
tends, therefore, to remove one of the chief dangers. 

As a large proportion of convulsive attacks originate in the condition 
of the intestines, either solely or in part, it is advisable to prescribe an 
aperient unless there is previous diarrhoeal. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia 
in the expulsion of seeds or other indigestible substances or scybala. A 
cathartic is also often required, especially if the enema fail to produce 
sufficient evacuations. In those that are robust, and especially in those 
beyond the age of two or three years, calomel is an excellent puroative, 
is easily given, and is prompt in its action. If the symptoms indicate 
intestinal inflammation, the milder purgatives, as castor oil, are prefer- 
able, as they also are in young or feeble children. If the recent in«-esta 
of the patient consisted of fruit or of substances of an indigestible charac- 
ter, an emetic is appropriate ; a teaspoonful of the syrup of ipecacuanha, 
repeated if necessary in fifteen or twenty minutes, may be given to a 
young child, or this syrup with the syrup, scillse compositus to one older 
and more robust. Aside from the ejection of the offendino- substance 
which it produces, an emetic has some effect in controlling the convulsive 
movements. But the cases are rare in which emetics are indicated. 



416 ECLAMPSIA. 

In addition to the local measures mentioned above, and measures calcu- 
lated to relieve the digestive canal of any offending substance, any safe 
medicinal agent which will act promptly in relieving the convulsions is 
urgently demanded, for eclampsia, if severe and protracted, involves great 
danger. Fortunately such agents have been lately introduced into thera- 
peutics, namely, the bromide of potassium or sodium, and hydrate of 
chloral. These agents, while they are effectual, are safe, and, therefore, 
their use has surpassed that of the antispasmodics, assafoetida, valerian, 
lavender, and chloroform ; no one of which, except the chloroform, exerts 
any direct controlling influence over the convulsions, and the chloroform 
is a dangerous remedy unless used sparingly. 

The bromide of potassium, which I prefer, should be given every ten 
minutes, dissolved in cold water, till the convulsions cease, in doses of 
three grains to a child of one year, and of four or five grains to a child of 
two or three years. When the convulsions cease, the interval between 
the doses should be of course lengthened. In one instance an infant of 
eighteen months was suddenly affected by eclampsia, and the mother in 
her fright mistaking the directions, gave thirty grains of bromide at one 
dose. Two hours afterwards, when I was able to attend, I found that the 
convulsions had ceased at once, and that the patient was playful. Such 
cases show the innocuousness of a large dose of the bromide. 

In severe cases the bromide does not always act with sufficient prompt- 
ness and power. The hydrate of chloral should then be employed, dis- 
solved in two or three drachms of water, and given with a small glass or 
gutta percha syringe per rectum. If used in sufficient quantity, and re- 
tained by pressure with a napkin, it is quickly absorbed, and will usually, 
in about fifteen or twenty minutes, control the movements. For a child of 
one year I employ about five grains, and for one of four years ten grains. 
With the employment of the measures indicated above, eclampsia is, in 
my practice, much more amenable to treatment than in former years. 
Unless the cause is such that recovery is impossible from the very nature 
of the case, the convulsions will soon cease with these measures. 

But additional treatment may be required, according to the pathological 
state which has brought on the eclampsia. If it be an eruptive fever, 
as scarlatina, and the eruption has receded, active revulsive measures, as 
hot mustard baths, are required ; if in dysentery, or other internal inflam- 
mation, the flax-seed and mustard poultice should be applied over the 
parts affected. 

In those dangerous cases in which symptoms of cerebral congestion 
continue after the eclampsia ceases, additional treatment is required. 
The child remains drowsy, does not speak, or apparently suffer in any 
way, and the pupils act less readily than in health. If this condition 
remain after the lapse of a few hours, there is probably serous effusion. 
All attacks of eclampsia, unless the mildest, are followed by a period of 



TETANUS INFANTUM. 417 

drowsiness, but the persistence of it, with symptoms which indicate 
hyperemia, with perhaps effusion within the cranium, calls for the em- 
ployment of additional measures. Vesication by cantharidal collodion 
should then be produced behind the ears, mild revulsives be applied to 
the extremities, the head kept cool, the bowels open, and, in certain cases, 
a diuretic like iodide of potassium may be advantageously employed. 
The utmost care should be enjoined in reference to the hygienic manage- 
ment of those who are subject to eclampsia. The diet should be nutri- 
tious, but bland, and all causes of excitement be studiously avoided. 



CHAPTER XII. 

TETANUS INFANTUM. 

Tetanus or trismus is one of the most interesting diseases of infancy. 
It is first, in point of time, in the long catalogue of fatal maladies. It 
occurs suddenly and unexpectedly in the robust as well as feeble, almost 
certainly destroying life within a few hours under modes of treatment 
heretofore employed. It is more frequent in some localities and condi- 
tions of life than in others. In New York it is more common than tetanus 
at any other age, or, indeed, in all other ages, since the mortuary sta- 
tistics of this city exhibit a larger number of deaths from this disease in 
the first year of life than subsequently. Infantile tetanus occurs, with 
very few exceptions, in the new-born. 

Interesting and important as is tetanus infantum, it must be confessed 
that our knowledge of it is much more limited and imperfect than it should 
be, when we consider what great advancement has been made in patho- 
logical inquiries during the present century. Our information in reference 
to its causation, symptoms, and proper treatment is not much in advance 
of that of M. Dazille, or Dr. Joseph Clarke, who lived in the latter part 
of the last century. 

Did we better understand the pathology of diseases in the new-born, or 
could we more accurately ascertain the condition of organs at this age, 
doubtless we should occasionally consider those phenomena which we now 
designate as a disease per se, under the title tetanus, as symptoms of some 
other affection. But as tetanic rigidity and spasms in the new-born occur 
so abruptly, masking all other symptoms, and ordinarily ending in death 
without our knowing certainly whether or not there is any antecedent 
disease, it seems entirely proper that we should recognize the state in 
which such muscular rigidity occurs with such a rapid result as an inde- 
pendent affection. This explanation is required from the fact that I have 
27 



418 TETANUS INFANTUM. 

added to the accompanying table one case from Billard, which this ob- 
server relates under the head of spinal meningitis. In this case, an infant 
three days old was attacked with convulsions. " His limbs were rigid 
and violently bent ; the muscles of the face were in a continual state of 
contraction." On the following day "the convulsions continued; . . . 
the body remained rigid, and the vertebral column, which the weight of 
the trunk will cause to bend with the greatest ease in a young infant, 
remained straight and immovable whenever the child was raised." At 
the autopsy, in addition to meningeal apoplexy, which is often present in 
those who die of tetanus infantum, a thick pellicular exudation was found 
upon the spinal arachnoid. There is, therefore, a strict accordance of the 
symptoms and history of this case with those which other observers describe 
as examples of tetanus infantum ; moreover, as a satisfactory reason for 
including this case in our statistics, certain eminent observers, as we will 
see, have reported epidemics of tetanus in which meningitis was the prin- 
cipal lesion. 

Fatal Cases. 

Case 1. Male ; taken when three days old ; lived sixty hours. Labatt, 
Edin. Med. and Surg. Jour., April, 1819. 
Female ; taken when three days old ; lived forty hours. Ibid. 
Taken when five days old ; lived fifty hours. Ibid. 
Taken when three days old ; lived one day. Ibid. 
Male; taken when two days old; lived two days. Billard, 

Treatise on Diseases of Children, Stewart's trans., p. 477. 
Male ; taken when three days old; lived two days. Romberg. 
Male ; taken when six days old ; lived ninety -three hours. Dr. 
Imlach; Month. Jour, of Med. Sci., Aug. 1850. 
" 8. Female; taken at five days; lived four days. Caleb Wood- 
worth, M.D., Boston Med. and Surg. Jour., Dec. 13th, 1831. 
" 9. Negro; taken at seven days; lived twenty-four hours. P. C. 
Gaillard, M.D., South. Jour, of Med. and Phar., Sept. 1846. 
" 10. Male ; taken when seven days old ; lived one day. Augustus 

Eberle, M.D., Missouri Med. and Surg. Jour., 1847. 
" 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Jour., 

Nov. 1846. 
" 12. Male; taken when three days old; lived one day. N. 0. Med. 

and Surg. Jour., May, 1853. 
" 13. Negro; taken when three days old ; lived three days. Robert 

H. Chinn, M.D., N. 0. Med. and Surg. Jour. 
" 14. Taken when two days old; died in four hours after the doctor's 

visit. Ibid. 
" 15. Taken when seven days old ; lived one day. C. H. Cleaveland, 

New Jersey Med. Rep., April, 1852. 
" 16. Negro ; taken when seven days old; death finally. Greenville 

Do well, Amer. Jour, of Med. Sci., Jan. 1863. 
" 17. Taken when twelve days old; lived one day. Thomas C. Bos- 
well, communicated to Dr. Sims, Amer. Jour, of Med. Sci., 
1846. 



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CASES. 419 

Taken when about five clays old ; died at about the age of nine 
days. B. R. Jones. Ibid. 

Taken at or soon after birth; lived two days. Dr. Sims, Amer. 
Jour, of Med. Set., April, 1846. 

Taken at the age of six days ; lived one day. Ibid. 

Taken when three days old ; lived two days. Ibid. 

Male ; taken at the age of eight days ; died in three hours. Com- 
municated to the writer. 

Taken at the age of twelve hours ; lived two days. Communi- 
cated to the writer. 

Female ; taken when seven clays old ; lived forty-five hours. The 
writer. 
25. Male ; taken at the age of seven days ; lived about forty-eight 
hours. Ibid. 

Female; taken at the age of eight clays; lived three days. Ibid. 

Female ; taken at the age of five days ; lived three days. Ibid. 

Female ; taken when four days old ; lived two days. Ibid. 

Taken when six days old ; died next day. Ibid. 

Taken when five days old ; lived twenty-four hours. Ibid. 

Taken when eight days old ; lived two days. Ibid. 

Male ; taken when five days old; lived one day. Ibid. 

Favorable Cases. 

Case 1. Negro ; female ; taken when three days old ; recovered in a few 
days. Robert S. Baily, Charleston Med. Jour, and Rev., Nov. 
1848. 

" 2. Negro ; taken at eleven days ; recovered in fifteen days. "W. B. 
Lindsay, N. 0. Med. Jour., Sept. 1846. 

" 3. Negro ; taken when ten days old ; recovered in thirty-one days. 
P. C. Gaillard, Charleston Med. Jour, and Rev., Nov. 1853. 

" 4. Male ; taken at the age of eight days ; recovered in twenty-eight 
days. Ibid. 

" 5. Negro ; taken at seven days ; recovered in fifteen days. Augus- 
tus Eberle, Missouri Med. and Surg. Jour., 1847. 

" 6. Taken when eight days old ; recovered in four weeks. Furlong, 
Edin. Med. and Surg. Jour., Jan. 1830. 

" 7. Taken at the age of one week ; recovered in two days. Dr. Sims, 
Amer. Jour, of Med. Sci., April, 1846. 

" 8. Female; taken at the age of three clays ; recovered in five weeks. 
The writer. 

Period of Commencement Finckh, who saw cases of tetanus of the 

new-born in the Stuttgart Hospital, states (Hecker's Annalen, vol. iii, No. 
3, p. 304) that it began in one case on the second day after birth, in eight 
on the fifth, and in seven on the seventh. 

Professor Cederschjold, of Stockholm, treated forty-two cases in hospital 
practice in 1834, and in these cases it usually commenced between the ages 
of four and six clays. Copland says {Medical Dictionary) that it generally 
commences in the first seven or nine days after birth, and rarely later than 
the fourteenth. Romberg states that it commences between the fifth and 



420 TETANUS INFANTUM. 

ninth days. In two hundred cases observed by Reicke, in Stuttgart, in 
the course of forty-two years, it was never found to commence before the 
fifth, rarely after the ninth, and never after the eleventh day. Schneider 
says that the disease occurs oftenest between the second and seventh, and 
rarely after the ninth day. In six cases reported by Dr. C. Levy, of 
Copenhagen, it began in two on the third day, in two on the fifth, and in 
two on the sixth. Dr. Greenville Dowell (Amer. Jour, of Med Sci., Jan. 
1863), who has seen much of tetanus infantum among the negroes in Mis- 
sissippi and Texas, says it is almost sure to come on between the fifth and 
twelfth days after birth. In the forty cases embraced in the above table, 
the disease began as follows : — 

Age. Cases. 

One day or under, ....... 2 

Two days, 1 

Three " 9 

Four " ........ 2 

Five " 6 

Six " 3 

Seven " 8 

Eight " 6 

Ten .1 

Eleven " 1 

Twelve " 1 

Very rarely, as will be seen hereafter, tetanus begins at or so soon after 
birth, that it may properly be called congenital. 

Frequency in Certain Localities. — Tetanus infantum occurs prob- 
ably in all countries, but it does not greatly increase the mortality except 
in certain localities. Some of the British and Continental physicians, whose 
observations of disease have been ample, confess that they have seen so few 
cases that they have almost no personal knowledge of this malady. On 
the other hand, there are, or have been, places in every zone where it is or 
has been so prevalent as to sensibly check the increase of population. The 
attention of the profession, more than a half century since, was directed 
to the prevalence of tetanus in the Island of Heimacy, off the coast of 
Iceland. On this island scarcely an infant escaped, while on the mainland 
scarcely one was affected. Heimacy, the product of volcanic action, of 
small extent and almost destitute of vegetation, supports a scanty popula- 
tion. The inhabitants live chiefly on the flesh and eggs of the sea-fowl, 
and are filthy and degraded in their habits. About the year 1810, the 
Danish government deputed the iandphysicus of Iceland to visit Heimacy, 
and ascertain the nature of the disease which was so destructive to the 
infants. Although this gentleman, from his brief stay, saw no case him- 
self, he obtained interesting particulars in reference to the disease from 
the priests and parents. At this time scarcely an infant escaped. Again, 
according to Dr. Schleisner, whose report in reference to the same locality 



FREQUENCY IN CERTAIN LOCALITIES. 421 

was published forty years later, tetanus was still the most fatal of all in- 
fantile maladies. 

Tetanus infantum is also represented as very fatal in the Island of St. 
Kilda, off the coast of Scotland. In the temperate regions of America 
and Europe cases are not frequent, except occasionally in the poor quarters 
of the cities, in foundling hospitals, and rarely in country towns where the 
conditions are favorable for its occurrence. The records of the Dublin, 
Stuttgart, and Stockholm lying-in asylums furnish many cases. In the 
town of Fulda, Germany, in 1802, Dr. Schneider saw six cases in four- 
teen days, while a midwife in the same place stated that she had seen 
more than sixty in nine years. 

But the greatest mortality from tetanus infantum is in the warm climates, 
both of the Eastern and AYestern Hemispheres. In the West Indies, the 
southern portion of the United States, the equatorial regions of South 
America, and in the islands of Minorca and Bourbon, it has, in many 
localities, been the most frequent and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United States 
the victims are chiefly negro infants. L. S. G-rier, M.D., of Mississippi, 
says, in the JS T . 0. Med. and Surg. Jour., May, 1851: "The first form of 
disease which assails the negro among us is trismus. The mortality from 
this disease alone is very great. No statistical record, we suppose, has 
even been attempted, but from our individual experience we are almost 
willing to affirm that it decimates the African race upon our plantations 
within the first week of independent existence. We have known more 
than one instance in which, of the births for one year, one-half became 
the victims of this disease, and that, too, in spite of the utmost watchful- 
ness and care on the part of both planter and physician. Other places 
are more fortunate, but all suffer more or less ; and the planter who escapes 
a year without having to record a case of trismus nascentium may con- 
gratulate himself on being more favored than his neighbors, and prepare 
himself for his own allotment, which is surely and speedily to arrive." 
Dr. Wooten (N. 0. Med. and Surg. Jour., May, 1816) says: "It is a 
disease of fatal frequency on the cotton plantations in this section of Ala- 
bama." He has, however, never seen a white child affected with it. 

In Xew Orleans, according to the death statistics in our possession, 
which, however, relate to only one year, tetanus infantum is the most fatal 
of all diseases except phthisis. Mr. Maxwell says, in the Jamaica Phys- 
ical Journal (copied in the London Lancet, April 11th, 1835): "From 
observations that I have made for a series of years, ... I found that the 
depopulating influence of trismus neonatorum was not less than twenty- 
five per cent. It scarcely has a parallel within the bills of mortality." 
This gentleman's observations relate to the West Indies. Similar state- 
ments are made in reference to this malady as it occurs in Cayenne and 
Demerara in South America. 



422 TETANUS INFANTUM. 

While tetanus infantum prevails in regions wide apart, and presenting 
very diverse climatic conditions, there is a similarity as regards the per- 
sonal and domiciliary habits of the people who suffer most from its occur- 
rence. It occurs chiefly among those who are filthy and degraded in their 
habits, who live, either from choice or necessity, in neglect of sanitary 
requirements. This fact aids us in an understanding of the — 

Causes — That uncleanliness and impure air are a cause of tetanus is 
as fully demonstrated as most facts in the etiology of diseases. The atten- 
tion of the profession was forcibly directed to this cause by Dr. Joseph 
Clarke in a paper read before the Royal Irish Academy in 1789. This 
physician was in charge of the Dublin Lying-in Asylum, and had rightly 
concluded that the mortality among the new-born infants was due to im- 
perfect ventilation. Through his advice, apertures, twenty-four inches 
by six, were made in the ceiling of each ward; three holes, an inch in 
diameter, were bored in each window-frame ; the upper part of the doors 
leading into the gallery were also perforated with sixteen one-inch aper- 
tures, and the number of beds was reduced. The result of these simple 
sanitary regulations may be seen from Dr. Clarke's own statement. He 
says: "At the conclusion of the year 1782, of 17,650 infants born alive 
in the Lying-in Hospital of this city, 2944 had died within the first fort- 
night, that is, nearly every sixth child." The disease in nineteen cases 
out of twenty was tetanus. After the wards were better ventilated, 
namely, from 1782 till the time of the preparation of Dr. Clarke's paper, 
8033 children were born in the hospital, and only 419 in all had died, or 
about one in nineteen. So impressed was Dr. Evory Kennedy, who at a 
later period had charge of the same asylum, with the belief that Dr. 
Clarke had discovered the true cause, and had been able in great meas- 
ure to prevent it, that he writes in his enthusiastic way: "If we except 
Dr. Jenner, I know of no physician who has so far benefited his species, 
making the actual calculation of human life saved the criterion of his im- 
provements." The cases occurring in my own practice have almost all 
been in tenement-houses, where habits of cleanliness are not observed, and 
I have not yet seen, in the practice of others, nor heard of a case which 
occurred in the better class of domicils. The statement of physicians in 
the Southern States, who speak from extensive observation among the 
negroes, are strongly corroborative of the idea that the disease is in great 
measure due to uncleanliness and impure air. 

Dr. Greenville Dowell, of Texas, states that he has been able to trace 
tetanus infantum to the bedclothes, saturated with excrementitious mat- 
ters, which are found in the negro cabins. In a paper published in the 
Nashville Journ. of Med. and Surg., June, 1851, by Prof. John M. Wat- 
son, the frequency of this disease among the negroes is accounted for as 
follows : — 

" When called to see their children, we find their clothes wet around 



causes. 423 

their hips, and often up to their armpits, with urine The child is 

thus presented to us, when, on examination, we find the umbilical dressings 
not only wet with urine, but soiled, likewise, with feces, freely giving off 
an offensive urinous and fecal odor, combined at times with a gangrenous 
fetor arising from the decomposition, not desiccation, of the cord." 

Another cause is believed to be some irritation in the intestines, as from 
retained meconium. Observers in the Southern States and elsewhere oc- 
casionally mention this as a cause. In one case treated by myself, there 
was obstinate constipation immediately before the attack, and in another 
diarrhoea preceded, and was the only apparent cause. 

In certain cases the assignable cause is exposure to wet or cold, or to a 
variable temperature, which, it is known, occasionally causes tetanus in 
the adult. Prof. Cederschjold attributed the epidemic which he observed 
in Stockholm to a sudden change of temperature, from hot weather in May, 
to frosty in June. In a case related by Dr. P, C. Gaillard, in the South- 
ern Jour, of Med. and Pharmacy, Sept. 1846, the disease commenced as 
follows : The nurse came in with wet apron and clothes, in the evening ; 
a short time after she had taken the child into her lap, it sneezed violently 
two or three times. At 10 P. M. tetanus began. In certain localities on 
the continent, where there are no parish churches, the frequent occurrence 
of tetanus has been attributed by the physicians to the practice of carry- 
ing the infants to a distance to be christened, thus exposing them to the 
winds. In this city I have observed tetanus after a similar exposure. 
The influence of the weather in the production of tetanus of the new-born 
is also shown by facts observed in the Stuttgart Hospital. In an aggre- 
gate of twenty-five cases treated in that institution, all but three occurred 
in the cold months. In the Island of Cayenne, at a hamlet surrounded 
by mountains and dense forests, tetanus attacked only one in every twelve 
or fifteen of the infants. After a great part of the forests had been cut 
down, so as to allow access to the cold sea winds, almost all the new-born 
infants fell victims to tetanus. (Insel, Cayenne.) 

Hein relates that a citizen of Berlin lost, successively, two children 
with tetanus soon after birth. When the second child fell ill he observed 
that its cradle was exposed to a current of air. At the third accouche- 
ment the position of the cradle was changed and the infant escaped. Ex- 
posure to wet and cold has been long recognized as a cause of the disease. 
According to Sauvages, " Hie morbus hieme et cum aura humida saspius 
advenit quam sicca estate." (Nosol. Method, vol. i, p. 531.) 

The causes of infantile tetanus, enumerated above, may be proximate 
or remote, may produce the disease by their direct effect on the system or 
by producing a pathological state which in turn leads to the development 
of the disease. There are other direct causes, namely, organic affections. 
In the bodies of those who die of this disease lesions are observed which 
doubtless result from the spasms. Again, others are found which, from 



424 TETANUS INFANTUM. 

their nature, could not be a result, and which, being observed in different 
cases, are to be regarded as direct causes. The most frequent of such 
lesions is inflammation of the umbilicus or umbilical vessels. 

Moschion, who lived in the first century of the Christian era, stated in 
writings still extant that stagnant blood in the umbilical vessels sometimes 
produced dangerous disease in the new-born infant, and it is supposed, 
though this is doubtful, that he referred to tetanus. In modern times the 
attention of the profession was more particularly directed to this cause 
by a paper published by Dr. Colles, in the first volume of the Dublin 
Hospital Reports, in 1818. The observations published in this paper were 
made in the Dublin Lying-in Hospital during* the period of five years. 
In each of these years he had witnessed from three to five post-mortem 
examinations in cases of infantile tetanus, and the lesions, he states, were 
in all much alike as follows : The floor of the umbilical fossa was lined 
by a membrane apparently formed by suppurative inflammation, and in 
the centre of this fossa was a large papilla. This papilla consisted of a 
soft yellow substance, apparently the product of inflammation, and in all 
the cases the umbilical vessels were in contact with this substance and 
were pervious. In a few instances superficial ulcerations were found near 
the mouth of the umbilical vein, and occasionally the skin surrounding 
the umbilicus was raised. The peritoneum covering the vein was highly 
vascular, often not to a greater distance than an inch above the umbilicus, 
but sometimes as far as the fissure of the liver. The peritoneum in the 
course of the umbilical arteries presented the inflammatory appearance 
in still greater degree, sometimes as far as the sides of the bladder. The 
connective tissue lying along the arteries and urachus anteriorly was 
loaded with a yellow watery fluid. The inner surface of the umbilical 
vein was not inflamed, but its coats, in general, were thickened. On slit- 
ting open the arteries, a thick yellow fluid, resembling coagulable lymph, 
was found within their coats, and in all cases these vessels were thickened 
and hardened as far as the fundus of the bladder. 

Dr. Finckh, who observed twenty -five cases in the Stuttgart Hospital, 
believes that the most frequent cause was suppuration or ulceration of the 
umbilical cord. In ten of the twenty-five cases the navel was dry and 
cicatrized ; in the remainder it was either wet or swollen, with a bluish- 
red inflamed edge at the margin of the navel ; a dirty viscid pus covered 
the umbilical depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, at- 
tended twenty -two cases in that institution in 1838 and 1839. Of these, 
twenty died, and fifteen were examined carefully after death. In fourteen 
there were decided marks of inflammation in the umbilical arteries, es- 
pecially those portions lying along the urinary bladder ; in several cases 
the peritoneum over the arteries was much injected, and in three adherent 
either to the omentum or intestine by coagulable lymph ; the coats of the 



causes. 425 

arteries were thickened, their cavities dilated and containing dark reddish- 
brown or greenish puriform matter, always fetid. Sometimes the arterial 
tunica interna was found ulcerated and absent in places, and there was 
spongy thickening of the subjacent connective tissue. In two cases the 
ulcerative process had extended from the tunica interna to the peritoneum, 
and there was a deposit of thick ichorous matter around the ulcer ; in 
one case both arteries were so softened that their coats were scarcely dis- 
tinguishable, and in another these vessels had become gangrenous. The 
appearance of the umbilicus was unchanged in four cases; in ten the 
fundus was red and filled with puriform fluid, which quickly reappeared 
when removed, and, in general, shortly before death, the navel presented 
a greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations 
in eighteen cases of tetanus infantum, and in fifteen found inflammation 
of the umbilical arteries. These vessels were swollen near the bladder, in 
one case to the diameter of four lines, and were found to contain pus. The 
lining membrane was eroded or covered with an albuminous exudation. 
Both arteries were not always equally inflamed, and in three cases only 
one was affected. 

Schneeman found minute points of suppuration in the umbilical vein in 
eight cases (tlolscher's Annalen, vol. v, p. -484, 1840), and pus throughout 
the course of this vessel in one. 

The observations mentioned above were made, for the most part, in 
hospitals on the Continent ; but similar observations have been made in 
private practice. M. Boiran, of the Isle of Bourbon, says that he has 
found in every case inflammation around the umbilicus (Gazette Medicate, 
Paris, July 11, 1841). Dr. John Furlonge (Edin. Med. and Surg. Jour., 
Jan. 1830), who resided at St. John's, Antigua, attributes the disease to 
improper dressing of the umbilicus. The same opinion is expressed by 
Mr. Maxwell, who also saw the disease in the West Indies (Jamaica Phys. 
Jour., copied into the London Lancet, April 11, 1855). Dr. Ransom 
states, in a communication to Prof. John M. Watson (Nashville Jour, of 
Med. and Surg., June, 1851) that he has never seen a case of tetanus of 
the new-born in which the umbilicus was healthy. In a case related by 
Robert S. Bailey, in the Charleston Med. Jour, and Rev., Nov. 1848, 
there was a hard scab on one side of the umbilicus, and this part was much 
distended. A discharge followed the removal of the scab, and the child 
recovered. In a favorable case, related by W. B. Lindsay, in the A. 0. 
Med. and Surg. Jour., Sept. 1846, the umbilicus was tumid, and not dis- 
posed to heal. Dr. H. O. Wooten (same journal, May, 1846) attributes 
the disease to the condition of the umbilicus and umbilical vessels, and 
states that he has found the umbilicus gangrenous. In a case related in 
the N. 0. Med. and Surg. Jour., May 1, 1853, the umbilical vessels were 
blocked up by purulent matter. Robert A. Chime, M.D., Brazoria, Texas 



426 TETANUS INFANTUM. 

(JV. 0. Med. and Surg. Jour., Sept. 1854), believes one cause of the dis- 
ease to be improper tying and management of the umbilical cord, by which 
a diseased state is produced, which extends to the umbilicus, and thence 
to the viscera. At a meeting of the Obstetrical Society of Edinburgh, 
held April 24, 1850, Dr. Imlach related a case in which there was a dark 
and gangrenous appearance of the integument around the umbilicus, and 
the peritoneum underneath was also dark, but not inflamed ; umbilical 
vein healthy ; a little fibrin in the left umbilical artery; right umbilical 
artery much diseased ; its two inner coats apparently destroyed, and in 
their place a yellow pultaceous slough, in which pus-globules were dis- 
covered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, and which has been noticed by so many observers 
in different countries, cannot result from the tetanus. It is possible that 
the puriform substance noticed in the umbilical vessels was disintegrated 
fibrin, which had coagulated at the time of ligation of the cord, and the 
cells seen by Dr. Imlach and others may sometimes have been white cor- 
puscles still remaining from the stagnated blood. ( Virchow's Cellul. Pathol.) 
Still, the evidences of inflammation, in at least a part of the cases related 
above, were of a positive character. 

The belief that umbilical lesions sometimes cause tetanus infantum com- 
ports with the well-known traumatic causation of tetanus in the adult. 
This belief is strengthened by the fact, which will appear further on in 
our remarks, that tetanus of the new-born, from being frequent in cer- 
tain localities, has become infrequent through greater care in dressing and 
managing the umbilical cord. 

But there are cases of tetanus infantum in which there is no disease in 
or about the umbilicus. Dr. Finckh, of Stuttgart, examined the umbilical 
vessels in eleven cases without discovering any pathological change. Dr. 
Samuel B. Labatt, master of the Dublin Lying-in Hospital, published in 
the Edin. Med. and Surg. Jour., April, 1819, a paper entitled " An In- 
quiry into an Alleged Connection between Trismus Nascentium and cer- 
tain Diseased Appearances in the Umbilicus." This paper was designed 
as a reply to the essay of Dr. Colles. Dr. Labatt relates several cases in 
which there was no disease of the umbilicus and umbilical vessels, and 
others in which the disease was so slight that it probably produced no in- 
jurious effect on the health of the child. Dr. James Thompson, who spent 
considerable time in the tropical regions, says {Edin. Med. and Surg. Jour., 
Jan. 1822) : " I have myself examined nearly forty cases of infants that 
have sunk under this complaint. In many I have looked at no other part 
but the navel, and have found it in all states ; sometimes perfectly healed, 
especially if the infants had lived several days ; at other times a simple 
clean wound. When death occurred on the fifth or sixth day, the wound 
was frequently in a raw state. I never yet saw it in a sphacelated condi- 



causes. 427 

tion." This writer concludes from his observations that there are cases in 
which the cause is located elsewhere than in the umbilicus or umbilical 
vessels. In the Dub. Jour, of Med. and Chem. Sci., Jan. 1836, Dr. John 
Breen remarks : " From dissections . . . we have never been able to dis- 
cover any peculiar morbid appearance which would justify us in offering 
any explanation of the pathology of the disease." In my own case there 
was no evidence of disease of the umbilicus or umbilical vessels so far as 
could be ascertained by external examination, and in one (No. 32) a care- 
ful post-mortem examination disclosed no lesion of these parts. 

The inference from the above observations is that, although umbilical 
disease may be an occasional, probably not infrequent, cause of tetanus 
infantum, cases occur in which such disease is not present, and we must 
look for the cause elsewhere. From the nature of tetanus infantum, the 
cerebro-spinal axis has been from time to time examined in those who 
have died of this malady, and occasionally sufficient cause has been found 
in this part of the system. 

I have alluded in another connection to a case from Billard, in which 
tetanic rigidity occurred in an infant three days old, as the result of spinal 
meningitis. That tonic spasms not infrequently occur in older children in 
consequence of meningeal inflammation is well known, and in some of the 
reported epidemics of infantile tetanus meningitis was really present, and 
was doubtless the cause of the tonic spasms. Such an epidemic was ob- 
served by Professor Cederschjold in Stockholm, in 1834. Within a few 
months he treated forty-two cases, and, in addition to the lesions which 
are known to result from tetanus, there was found in the bodies examined 
a plastic exudation at the base of the brain. Finckh, of Stuttgart, made 
twenty post-mortem examinations of those who had died of this disease, 
and in nine found spinal meningeal inflammation. 

Meningitis in the new-born infant is, however, rare, and we must regard 
it as an exceptional cause of tetanus. 

In 1846 there appeared from the pen of Dr. Sims, then practising at 
Montgomery, Alabama, a paper designed to show that tetanus of the new- 
born is produced by pressure exerted on the nervous centre, through de- 
pression of the occipital bone. In 1848 the same writer published a second 
paper, also, in the Amer. Jour, of Med. Sci., fully enunciating his theory as 
follows : " That trismus neonatorum is a disease of centric origin depending 
on a mechanical pressure exerted on the medulla oblongata and its nerves ; 
, that this pressure is the result, most generally, of an inward displacement 
of the occipital bone, often very perceptible, but sometimes so slight as to 
be detected with difficulty ; that this displaced condition of the occiput is 
one of the fixed physiological laws of the parturient state; that when it 
persists for any length of time after birth it becomes a pathological condi- 
tion, capable of producing all tlie symptoms characterizing trismus neona- 
torum, which are instantly relieved simply by rectifying this abnormal 



428 TETANUS INFANTUM. 

displacement, and thereby removing pressure from the base of the brain." 
In both papers cases are narrated in support of this theory, but there are 
serious objections to this mode of explaining the occurrence of the disease. 
In the first place, if this explanation were correct, tetanus ought ordinarily 
to occur sooner, for the occiput is as much depressed previously, and in the 
majority of cases more depressed than at the period when it does actually 
commence. Pressure on the medulla would certainly be followed by im- 
mediate and marked symptoms, instead of an immunity for four or five 
days. 

Again, well-known facts in reference to the causation of tetanus infantum 
conflict with Dr. Sims's theory, as, for example, epidemics of the disease, 
its prevalence in one locality and absence in another, although no particu- 
lar attention is given to the position of the infant, the diminution of the 
number of cases by greater attention to cleanliness, of which there is 
abundant proof. Moreover, there are many reported cases of this disease 
at the commencement of which there was no perceptible displacement of 
the occipital bone. 

The inequality of the cranial bones often observed in tetanus infantum 
should, in my opinion, be explained as follows : When the new-born 
infant becomes emaciated the volume of the brain is diminished, like that 
of the trunk or limbs, and the sinking of the occipital bone simply corre- 
sponds with the amount of waste in the cerebral substance. Whatever 
the disease in the young infant, if there is much emaciation, the parietal 
bones will usually be found more prominent than the occipital. Now, in 
fatal tetanus infantum emaciation is very rapid ; those fleshy and plump, 
if the disease do not speedily end, become pinched and wrinkled. Viewed 
in this light, the occipital depression should be regarded as a result, and 
not cause, of the tetanus. 

Although we do not accept the theory which attributes tetanus infantum 
to occipital depression, there are a few cases on record in which it was ap- 
parently due to injury of the head received at birth. Dr. Sims has related 
one such case, that of a negro infant. The mistress, an observing lady, 
gave to Dr. Sims the following account of it : Its head was " mightily 

mashed The bones seemed to be loose. I got it to take a little 

boiled milk on the first day ; but it swallowed very little and very badly, 
for its jaws seemed to be locked. On the next day it took spasms and got 
stiff all over ; its hands were shut up tight, and its arms were bent up so 
(she placed her forearms at right angles). Every time I touched it the 
spasm would get worse all over, screwing up its face till it was the ugliest 
thing in the world; and when the spasms wore off it looked as well as any 
other new-born baby. But then the stiffness never left it, and the spasms 
kept coming and going till it died." It lived two days. 

It is evident, from the description given by the mistress, that this was a 
case of tetanus commencing at or so soon after birth that it seemed almost 



causes. 429 

congenital. The apparent cause was injury of the head, occurring in con- 
sequence of protracted birth, the infant being resuscitated with difficulty 
after several minutes. 

Dr. W. C. Sutton published a similar case in the Nashville Jour, of 
Med. and Surg., April, 1853. The infant at birth was apparently dead, 
but was resuscitated so as to live eighteen hours in a state of tetanic 
rigidity. In cases in which tetanus begins at birth, doubtless, the cerebro- 
spinal axis is in some way affected ; but in the absence of post-mortem 
examinations, the exact nature of the lesion is uncertain. 

It is evident, therefore, that in this disease, as in eclampsia, the cause 
in different cases may be entirely distinct. Dr. James Johnson, many 
years ago, expressed his belief in the multiplicity of causes, and he had 
been a careful and intelligent observer in the West Indies. 

The causes may be arranged in two groups, one external, the other 
internal. In the first group should be placed imperfect ventilation, per- 
sonal and domiciliary uncleanliness, and atmospheric vicissitudes ; in the 
second group, so far as ascertained, inflammation of the umbilicus and 
umbilical vessels, meningitis, and, rarely, injury of the cerebro-spinal axis 
during birth. 

The lesions resulting from tetanus infantum pertain chiefly to the cir- 
culatory system. In the cases examined by Professor Cederschjold, of 
Stockholm, already alluded to, the meningeal and cerebral vessels, and 
those of the spinal cord, the cavities of the heart, and the large vessels 
connected with the heart, were distended with blood. 

Finckh made post-mortem inspection of twenty cases in the Stuttgart 
Hospital, the bodies, at death, having been placed on their faces, in order 
to prevent any deceptive appearance from the gravitation of blood. In 
four there was no appreciable alteration in the spinal cord or its mem- 
branes. In the remaining sixteen there was effusion of blood, in con- 
siderable quantity, the whole length of the spinal cord, between the bony 
walls and the dura mater. It should be stated, however, that there was 
spinal meningeal inflammation in nine of the sixteen, though the extra- 
vasation did not, probably, result from the inflammation, but from the 
tetanus. The blood in Finckh's cases was very dark, sometimes fluid, at 
other times coagulated. In one case there was no change in the appear- 
ance of the brain or its membranes. In the remaining nineteen, more or 
less extravasated blood was found on the surface of the brain, or in its 
interior. The substance of the brain was healthy, as also its membranes, 
except the congestion. The only abnormal appearance observed in the 
thoracic and abdominal viscera was strong contraction of some portion 
of the intestinal tube in five cases. Dr. West says: "The most frequent 
post-mortem appearances in these cases" — referring to tetanus infantum — 
" and that which I found in the bodies of all the four children whom I 
observed, consists of effusion of blood, either fluid or coagulated, into the 



430 TETANUS INFANTUM. 

cellular tissue surrounding the tlieca of the cord. Conjoined with this 
there is generally a congested state of the vessels of the spinal arachnoid, 
and sometimes an effusion of blood or serum into its cavity. The signs 
of congestion about the head are less constant, though much oftener pre- 
sent than absent, and sometimes existing in an extreme degree ; while in 
one instance I found not merely a highly congested state of the cerebral 
vessels, but also an effusion of blood, in considerable quantity, between 
the skull and dura mater, and also a slighter effusion into the arachnoid 
cavity." Dr. Weber, of Kiel, also placed infants who had died of tetanus 
on their faces, and, without exception, found injection of the capillaries of 
the cord and spinal meninges, and extravasation of blood. M. Matus- 
zynski, according to Bouchut, " has observed effusions of blood of variable 
quantity, in the cerebral pia mater, in the ventricles, and in the choroid 
plexuses, with considerable injection of the membranes of the brain. He 
has also seen serous infiltration beneath the arachnoid, and serous effusion 
into the ventricles, accompanied by a diminution of the consistence of the 
cerebral substance." In two cases examined by myself there was intense 
injection of the cerebral meninges and of the meninges of the upper part 
of the spine, but no extravasation was noticed. The spinal canal was not 
opened. In a third case, in which the spinal canal was opened, there was 
extravasation in addition to the congestion ; this was especially observed 
along the spinal theca. 

Dr. H. O. Wooten (N. 0. Med. and Surg. Jour., May, 1846) states 
that he has made several post-mortem examinations, and has found the 
pathological appearances as uniform as in any other disease, as follows : 
" Engorgement of the substance of the brain, and of the meninges lining 
the base of the brain, the medulla oblongata, and spinal marrow ; liver 
congested." 

In a case related by Dr. Imlach before the Edin. Obst. Soc, April 24th, 
1850, the upper part of the lungs was healthy, the posterior portion con- 
gested, and containing many dark points ; heart and liver healthy ; small 
intestines of a light-brown color ; stomach and large intestines pale ; there 
had been umbilical hemorrhage. 

Romberg states that he found in a child, whose death occurred from this 
disease, such intense congestion of the veins and sinuses of the brain, that 
a slight touch, and the removal of the cranial bones, produced extravasa- 
tion of the partly coagulated and partly fluid blood. Dr. Scholler, on the 
other hand, found actual extravasation of blood in the spinal canal in only 
one case in eighteen. 

It is seen from the above observations, that tetanus of the infant is ordi- 
narily accompanied by great passive congestion, which is especially marked 
in the cerebro-spinal axis, and that frequently extravasations occur from 
the distended capillaries. The embarrassment of respiration and the re- 



SYMPTOMS. 431 

tarded circulation of blood consequent on the tetanic rigidity, afford suffi- 
cient explanation of this state of the vessels. 

Symptoms In many cases premonitory symptoms are absent, or are 

so slight as to escape notice. Sometimes there is a degree of fretfulness 
previously, but no more than is often observed in those who continue in 
good health. The first symptom which alarms the parents, and shows 
the grave nature of the commencing disease, is inability to nurse, or evi- 
dent pain and hesitation in nursing. Commencing with rigidity of the 
masseters, the disease gradually extends to the other voluntary muscles, 
and in the course of a few hours the muscles of the limbs, as well as of the 
trunk, are involved. Persistent muscular contraction, which is the 
pathognomonic feature of infantile tetanus, is developed not fully in the 
beginning, but by degrees in each affected muscle, so that it is not till 
after the lapse of several hours, perhaps even a day, that the greatest 
amount of rigidity is attained. Therefore, in the commencement of the 
disease, the limbs can be bent, and the jaws pressed open, more readily 
than at a subsequent stage, though with manifest pain to the infant. 

During the period of maximum rigidity, the jaws are fixed almost im- 
movably, often with a little interspace between them, against which the 
tongue presses, and in which frothy saliva collects. The head is thrown 
backward and held in a fixed position by the stiffness of the cervical mus- 
cles. The forearms are flexed ; the thumbs are thrown across the palms 
of the hands, and are firmly clenched by the fingers ; the thighs are drawn 
towards the trunk ; the great toes are adducted, and the other toes flexed. 
Occasionally opisthotonos results from the extreme contraction of the 
dorsal and posterior cervical muscles. The infant can sometimes be 
raised without any yielding of the muscles, by one hand under the occiput 
and the other under the heels. 

The rigidity is liable to variation in its intensity, even after the full 
development of the disease. If the infant is quiet, especially if asleep, the 
muscles are partially relaxed to such an extent, sometimes in the first 
stages of the complaint, that the features have a placid and natural ex- 
pression, though only for a short time. There are frequent exacerbations 
in the muscular contraction, sometimes occurring without any apparent 
cause, and sometimes produced by anything which excites or disturbs the 
child. Attempts to open the lips or jaws, or eyelids, or to bend the limbs, 
blowing on the face, or even the crawling of a fly upon it, occasions the 
paroxysm. 

During the paroxysm the eyelids are forcibly compressed, as well as 
the lips, which are either drawn in or are pouting ; the forehead and 
cheeks are thrown into wrinkles, and the physiognomy is indicative of 
great suffering. The unnatural positions of the trunk and limbs, which 
result from the muscular contraction, are increased for the moment ; the 
head is more forcibly thrown back, and the limbs more strongly flexed. 



432 TETANUS INFANTUM. 

The muscular movements which occur during the paroxysms are some- 
times described as clonic spasms. There is indeed occasionally some 
quivering of the limbs, and yet, as I have on different occasions noticed, 
so far from the muscular action being a clonic spasm, it possesses a tonic 
character, which is at times intensified. In fatal cases the paroxysms 
occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, however great 
the suffering. It is variously described by writers as " whimpering" or 
" whining." It is of this suppressed character in consequence of the rigid 
state of the respiratory muscles and their imperfect movement. 

During the exacerbation respiration is suspended, or so imperfect, and 
the circulation so retarded, that the surface becomes of a deep red, almost 
livid, color. Sometimes epistaxis occurs, affording partial relief to the 
congestion, and sometimes, though less frequently, the blood forces itself 
from the congested liver along the umbilical vein, and escapes from 
the umbilicus. I have already alluded to the occurrence of meningeal 
apoplexy. 

The frequency of the pulse and respiration varies in different cases, and 
at different stages of the same case. They are often somewhat accelerated, 
but at other times are natural, or are even slower than in health. 

While the appetite of the infant, to appearance, is not diminished, the 
pain which it experiences in nursing is such that alimentation is neces- 
sarily deficient. It can be fed with a spoon for a time after it ceases to 
take food in the natural way, but artificial feeding soon fails. The milk 
placed in its mouth is in great part pressed back through the violence of 
the spasm which is induced by the attempt to feed it. 

In consequence of imperfect nutrition, the infant rapidly wastes away. 
There is no other disease except the diarrhoea! affections in which emacia- 
tion is so rapid. In a case related by Dr. W. B. Lindsay in the N. 0. 
Med. Jour., Sept. 1846, the record states that " the infant was fat three 
days before, but was now emaciated." Romberg, who saw tetanus in- 
fantum in European hospitals, and Dr. Robert H. Chinn, of Texas (N. 
0. Med. and Surg. Jour., Sept. 1854), both speak of the rapid emacia- 
tion. The trunk and extremities lose their fulness, and the features be- 
come pinched. Several observers have noticed the appearance of miliaria 
in this reduced state of system, especially around the shoulders, and some- 
times a decidedly icteric hue appears on the skin. 

The condition of the intestines is not uniform. They may be relaxed, 
particularly if the disease is due to some irritation in them ; in other cases 
the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts to 
open the eyelids bring on spasms and cause firm compression of the lids 
against each other. According to Sir Henry Holland, one of the first symp- 
toms which occurred in cases on the Island of Heimacy, was strabismus, 



PROGNOSIS. 433 

with rolling of the eyes. But this statement must be received with caution, 
since these cases were not seen by any physician, and the information was 
obtained from the parents and priests. If true, the proximate cause of the 
disease in Heimacy would seem to be located in the cerebro-spinal axis. 
Contraction of the pupils commonly occurs in the stage of collapse. 

Mode of Death Death in infantile tetanus may occur from apncea 

in the paroxysms, from extreme congestion of the cerebral vessels, or 
apoplexy ; and, lastly, it may occur from exhaustion. The last mode is, 
probably, the most frequent. 

Prognosis All writers till recently agree that tetanus of the infant 

rarely terminates favorably. Cullen attributes the ignorance of physi- 
cians in regard to this disease to the fact that it is so little amenable to 
treatment, that they are not usually summoned to attend those affected 
with it. In the island of Heimacy, of one hundred and eighty -five cases, 
occurring during a series of years about the commencement of the present 
century, not one survived ; and in the same locality, at a more recent 
period, according to the report of Dr. Schleisner already alluded to, sixty- 
four per cent. died. Similar statements in regard to the mortality of 
tetanus infantum are given by physicians in the Southern States. Dr. 
H. 0. Wooten, of Alabama, says (K 0. Med. Jovrn., May, 1846) that he 
has " never seen a decided case of tetanus nascentium that did not prove 
fatal ; . . . and that it is very generally deemed useless to call in medical 
aid after the initiatory symptoms are well declared." Mr. Maxwell, speak- 
ing in reference to the West Indies, says (Jamaica Phys. Journ., copied into 
the London Lancet, April 11th, 1835): " From observations which I have 
made for a series of years, ... I found that the depopulating influence 
of trismus nascentium was not less than twenty-five per cent. It scarcely 
has a parallel within the bills of mortality." Dr. D. B. Nailer (A 7 ". 0. 
Med. Journ., Nov. 1846) says : " About two-thirds of the deaths among the 
negro children are from this disease, and so uniformly fatal is it, that a 
physician is never sent for." 

Yet death does not always result. Eight of the forty cases in my col- 
lection recovered ; but a correct opinion cannot be formed from this of the 
actual ratio of favorable to unfavorable cases, since favorable cases are 
much more likely to be published. In the history of these eight cases, two 
interesting facts are noticed, which, when present, may serve as a ground 
for hope of a successful termination. These were, the age at which the 
disease began, and fluctuation in the symptoms. With two exceptions, the 
infants who recovered were about a week old when the initiatory symptoms 
appeared, and there were fluctuations in the gravity of the symptoms ; 
whereas, fatal cases ordinarily grow progressively worse. Yet, in favorable 
cases, the symptoms are never so severe as they become in a few hours in 
those who succumb. 
28 



434 TETANUS INFANTUM. 

Duration in Fatal Cases — Of eighteen cases observed by Finckh in 
the Stuttgart Hospital, fifteen died in two days, two in five days, and one 
in seven days. During the epidemic in the Stockholm hospitals, in 1834, 
where forty-two cases were treated, the disease seldom lasted more than 
two days. Romberg says: " It generally lasts from two to four days, but 
its duration is at times limited at from eight to twenty-four hours, and 
occasionally, though rarely, it extends from five to nine days." 

In thirty-one fatal cases in my collection, in which the duration is men- 
tioned — 

One lived ....... 3 hours. 

Eleven others lived . . . . .1 day or less. 

Twelve lived ....... 2 days. 

Four " 3 " 

Three " 4 " 

Both Underwood, who published a little treatise on diseases of children, 
in 1789, and Dr. Elsasser, at a more recent date, record fatal cases which 
were unusually protracted. The one described by Underwood was treated 
in the British Lying-in Hospital, and, although all the others treated in 
this institution died by the third day, this lived six weeks ; but it is sug- 
gested by the author, that death was due in part to some other affection. 
The child treated by Elsasser lived thirty-one days. 

Duration in Favorable Cases In the eight favorable cases in my 

collection, the duration of the disease, reckoned from the time when the 
infant ceased nursing till it began again, was as follows : In one case, two 
days ; in one, a few days ; in one, fourteen days ; in two, fifteen days ; in 
one, twenty-eight days; in one, twenty-one days; and in the remaining 
case, about five weeks. 

Diagnosis To one who has seen this disease in the new-born, or is 

familiar with its symptoms, diagnosis is easy. The symptoms which possess 
diagnostic value are more manifest and reliable than in most other infan- 
tile affections. Permanent rigidity of the voluntary muscles, with tem- 
porary exacerbations, such as have been described above, which are induced 
by any cause which disturbs the infant — as attempts to open the mouth or 
eyelids — is pathognomonic. 

Preventive Treatment. — While tetanus infantum, if fully developed, 
is ordinarily fatal, in spite of any remedial measures heretofore used, there 
is no doubt of the efficacy and value of preventive measures, when prop- 
erly employed. This was shown by the great reduction in mortality in 
the Dublin Lying-in Hospital through the thorough ventilation introduced 
by Dr. Clarke. Dr. Meriwether, of Montgomery, Ala., says (Amer. Journ. 
of Med. Set., April, 1854): " When the disease appears endemically on a 
plantation, it may be arrested by having the negro houses whitewashed 
with lime, inside and out; by raising the floors above the ground; by 
removing all filth from under and about the houses ; by particular atten- 



TREATMENT. 435 

tion to cleanliness in the bedding and clothes of the mother ; and in the 
dressing of the child, so as to prevent any of the matter from the umbilicus 
lying long in contact with the skin." Many physicians, especially in the 
Southern States, speak confidently of care in dressing the cord, and atten- 
tion to the umbilicus, as a means of prevention. In the 2V. 0. Med. and 
Surg. Journ., July, 1853, Dr. Grafton says that- he has " never known the 
disease to occur in any child whose navel had the turpentine dressing." 
He uses turpentine us follows: "At the first time, a few drops of the 
undiluted turpentine are applied immediately to the umbilicus around the 
cord, and it is anointed at every succeeding dressing, the turpentine being 
diluted one-half or two-thirds with olive oil, lard, or fresh butter." This 
use of turpentine has also been recommended by other practitioners in the 
warm regions. 

Dr. John Furlonge, of St. John's, Antigua, believes (Edin. Med. and 
Surg. Jour., Jan. 1830) that no case would occur with the following treat- 
ment: " The cord, when divided, should be wrapped in clean linen. Every 
night, for two weeks, one or two drops of tinct. opii and spts. vini, equal 
parts, should be given, and castor oil, with a little magnesia, every morn- 
ing. The child must be washed in tepid water every morning, and the 
funis dressed." If this treatment is attended by the success which is 
claimed for it by Dr. Furlonge, so great care in dressing the cord is cer- 
tainly well repaid in localities, as at Antigua, where a large proportion of 
the infants die of tetanus. 

Some experienced observers go so far as to assert that it is possible to 
ward off tetanus infantum after the occurrence of premonitory symptoms. 
Dr. Dowell says (A?ner. Jour, of the Med. Sci., January, 1863) : "Some, 
with slight twitchings of the muscles, have recovered without any trouble 
by being put into a mustard-bath, washed clean, and put in a clean and 
well- ventilated cabin." 

Treatment. — In considering the effect of medicinal agents which have 
been employed in the treatment of infantile tetanus, the great difficulty 
which the child experiences in swallowing should be borne in mind. 
Without care, a considerable part of the dose is lost by the spasm of the 
muscles of deglutition, which ordinarily occurs when the spoon is placed 
in the mouth, so that, unless special attention is given to this matter, it is 
uncertain whether the prescribed dose is fully administered. 

The treatment employed by different physicians has been very diverse. 
Antiphlogistic remedies were prescribed by Finckh, but every case so 
treated was fatal. He states that whenever blood was abstracted, even in 
small quantities, the symptoms were aggravated. The same result has 
followed depletory measures in the practice of other physicians. 

The internal remedies which have been most frequently prescribed are 
opiates and antispasmodics. Furlonge, in a favorable case, gave lauda- 
num, in doses of one drop every three hours, alternately with two grains 



436 TETANUS INFANTUM. 

of Dover's powder. "Woodworth also gave one-drop doses of laudanum ; 
Eberle, one-sixth of a drop hourly. The opiate has generally been given 
in combination with an antispasmodic. The Dover's powder, given every 
three hours by Furlonge, was combined with five grains of sulphate of 
zinc. The hourly doses of laudanum, by Eberle, were combined with six 
drops of tincture of assafoetida. 

When anaesthetics began to be employed in the treatment of diseases it 
was believed that they would be especially useful in cases of tetanus. 
Accordingly chloroform has been used in tetanus in the infant, with the 
effect of controlling the spasm during the time of its use, but without 
curing the disease. In Case 7 in our first table it was employed several 
times, but apparently without delaying the fatal result. The editor of the 
New Orleans Medical and Surgical Journal states, in the May issue of 
that periodical for 1853, that he has used chloroform in tetanus infantum, 
with the effect, he believes, of prolonging life. Anaesthetics certainly re- 
lieve the suffering of the infant, and on this account, even if they do not 
prolong life, their judicious employment seems proper. 

The remedy which, in my opinion, is far preferable to all others, is hy- 
drate of chloral. Since the introduction of this agent into therapeutics, 
it has been employed by several physicians in the treatment of this disease 
with so good a result that it will probably supersede all other medicines 
for this purpose. Dr. Widerhofer, of Vienna, states that he has saved 
six out of ten or twelve by the use of chloral {London Lancet, March 18th, 
1871). He prescribes it in doses of one to two grains by the mouth, or, 
if there is great difficulty in swallowing, two or four grains by the rectum. 
Dr. F. Auchenthales relates a case (Jahrb.f. Ivinderheil.ylS. S., IV.) in 
which he gave even six grain doses, and in nine days the disease had en- 
tirely disappeared. I have employed hydrate of chloral in only one case 
of tetanus infantum, giving it in half-grain doses, every two hours, except 
when there was profound sleep. The disease was fully developed, and the 
symptoms severe when I was called. I did not believe that the infant 
with the old remedies would live more than two days, but by the chloral 
life was prolonged nearly one week. Moreover, by the use of chloral the 
suffering of the infant is greatly diminished. 

The administration of alcoholic stimulants is required at short intervals 
on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which there 
is evidence of inflammation of the umbilicus or umbilical vessels should 
not be neglected. Vesication of the umbilicus, and the application of 
poultices to it, have been followed by unquestionable benefit, if we may 
believe the statement of some physicians who have made use of these 
measures. Dr. Merriwether, of Alabama, says, if there is no improve- 
ment from the medicine which he orders, he applies a blister, larger than 



INTERNAL CONVULSIONS. 437 

a dollar, to the umbilicus, and with this treatment the child generally im- 
proves ; a remarkable statement, since so few improve at all. 

A warm foot-bath, repeated at intervals of a few hours, and stimulating 
embrocations along the spine, are proper adjuvants to the treatment. 



CHAPTER XIII. 

INTERNAL CONVULSIONS. 

Young- children are liable to temporary suspension of respiration, in- 
duced by violent emotions, especially by anger. In the midst of their 
excitement, while they are crying or screaming, their breath is suddenly 
held, as if from tonic spasm of the respiratory muscles. In a few seconds 
respiration returns and is natural. There is no stridulous inspiration or 
other unusual sound, and there is no apparent ill effect, unless occasionally 
a degree of languor. External convulsions, which seem to be threaten- 
ing, seldom occur, and when they do, are ordinarily mild. Some writers 
consider dentition the predisposing cause of this arrest of respiration, by 
inducing a sensitive state of the nervous system. Such an effect of den- 
tition is possible, but certainly many infants are affected in this manner 
before the age of dentition. 

A much more serious state, and one which is recognized as a true dis- 
ease, is that variously designated by writers as internal convulsions, spasm 
of the glottis, child-crowing, laryngismus stridulus, etc. Manifest diffi- 
culties attend the investigation of the pathological state in this disease. 
There can be little doubt that it is not precisely the same in all cases. 
That there is, during the paroxysms, tonic or clonic spasm of more or 
fewer of the respiratory muscles is inferred not only from the symptoms 
pertaining to the respiratory apparatus, but from the fact that in severe 
cases there are often spasms of the external muscles, as those of the limbs 
and face. Usually, also, the movements of the eyeballs indicate spas- 
modic contractions of the motor muscles of the eyes. The occurrence of 
these contractions in parts that are visible justifies the belief that they 
occur in other parts which are concealed from view, especially as the 
characteristic symptoms cannot be readily explained except on this suppo- 
sition. Trousseau says : " Internal convulsions consist, then, principally 
in a spasm of the diaphragm and of the respiratory muscles of the abdo- 
men and chest ; but it occurs, also, that the muscles pertaining to the 
larynx are affected with spasm at the same time with these." Rilliet and 
Barthez conclude from the symptoms that the " heart is not always a 
stranger to this internal convulsion, which, perhaps, prolongs itself even 



438 INTERNAL CONVULSIONS. 

to the intestines," The muscles of the pharynx appear to be involved, in 
some cases, as well as those of respiration, rendering deglutition difficult. 
In one form of internal convulsions, namely, that which is principally 
referred to by writers, there is not complete arrest of respiration, but the 
inspirations, during the paroxysms, are difficult and are attended by a 
stridulous noise. Again, the respiration may cease entirely, but when it 
commences it is stridulous, and difficult for a few inspirations. In still 
another form of the disease respiration ceases, but there is no symptom or 
sign indicative of glottic spasm or of an obstacle to the ingress of air ; 
the inspirations which succeed the paroxysm are easy and noiseless. It 
has been suggested that, in these cases, there is paralysis rather than 
spasmodic contraction of the respiratory muscles, but the symptoms may 
be explained in accordance with the commonly accepted opinion, namely, 
that there is spasm of the diaphragm and, perhaps, of certain muscles 
of the chest and abdomen, while the laryngeal muscles are not affected. 
M. Herard, indeed, who has written one of the best monographs on in- 
ternal convulsions, describes three forms of the disease, according to the 
supposed location of the spasm, namely, laryngeal, diaphragmatic, and 
another, which consists of a blending of the two, 

Internal convulsions are not frequent in this country ; they are rare 
in France, more frequent in Germany, and quite common in England. 
They occur, with few exceptions, before the age of two years. Dr. West 
observed thirty-one cases under the age of two years, and only six above 
that age. 

Causes. — The causes of internal convulsions are not fully ascertained. 
Most observers have remarked the relative frequency of the disease during 
the period of dentition, and it is probable that dental evolution does ope- 
rate as a cause, by rendering the nervous system more impressible. 

Spasm of the glottis has been attributed to enlargement of the thymus 
gland, and also to enlargement of the cervical and bronchial glands. It 
is presumed that this effect is due to the pressure of these glands on the 
par vagum, or the recurrent laryngeal nerve. It is certain, however, that 
there is no such enlargement of the thymus gland which could possibly 
produce glottic spasm, or any other form of internal convulsions at the 
ao-e at which these convulsions commonly occur. This gland is largest in 
the new-born, and having no function after birth, it gradually becomes 
atrophied. If enlarged thymus could produce glottic spasm, it would 
certainly occur most frequently in the new-born. Abnormal development 
of the thymus gland was the only assignable cause of atelectasis in two 
infants who died soon after birth, but I have never seen a case in which a 
convulsive attack was referable to this cause. M. Herard examined the 
thymus gland in six children who died of internal convulsions, and in 
sixty who died of other affections, and was not able to discover in its 
condition any causative relation to this disease. Indeed, cases have been 



causes. 439 

reported in which the thymus had undergone more than its usual atrophy 
at the time when the convulsions occurred (Hasse). Enlargements of 
the lymphatic glands in the vicinity of the pneumogastric or recurrent 
laryngeal nerve may possibly give rise to glottic spasm, but this is doubt- 
less an infrequent cause, if it be a cause at all, since these glands are often 
greatly enlarged in strumous and tubercular diseases without such a result. 
According to Dr. Jacobi (JV. Y. Jour, of Med., Jan. 1860) : "In some 
cases, described by Dr. Friedleben, a congenital hypertrophy of the thy- 
roid gland has probably been the cause of laryngismus. The patients 
were new-born infants of normal development, and born by normal labors. 
There were no constitutional causes of the disease, but a remarkable vas- 
cular swelling of the thyroid gland. Whenever the swelling increased, 
the veins of the face and head increased in size also, the face grew livid, 
and the extremities and spinal column exhibited slight tonic convulsions. 
The recurrent nerves were entirely surrounded by the glandular tissue, 
their neurilemma looked unusually red, and their functions were probably 
injured during the occasional swelling taking place during lifetime." 

The cause is occasionally located in the cerebro-spinal axis. Thus Dr. 
Coley relates a case in which an exostosis arising from the internal surface 
of the occipital bone pressed upon the cerebellum, while nothing abnormal 
was discovered in other organs. There are also striking examples in which 
the cause was located in the spinal cord. Thus Marshall Hall relates the 
following case communicated to him. A child with spina bifida was at- 
tacked with croup-like convulsions, whenever it lay so as to press on the 
tumor. 

Internal convulsions also frequently occur in rachitic softening or de- 
formity of the calvarium, since, when this is present, undue pressure occurs 
upon the brain, even by the weight of the head of the child upon the 
pillow. 

In some patients there is evidently an hereditary predisposition to this 
disease ; those affected belonging to families in which there is a tendency 
to convulsive maladies. Thus Toogood relates that five infants of the 
same family were affected with spasm of the glottis ; and Reid relates, on 
the authority of Powel, that of thirteen infants of the same parents only 
one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous 
system, often associated with impaired general health. Hence the disease 
is more prevalent in cities, where anti-hygienic conditions abound, than 
in the country. Hence, too, the frequent improvement when the patient 
is removed to the pure and bracing air of the country. The use of insuf- 
ficient food, or food of a bad quality, must for the same reason be con- 
sidered a cause, as it leads to impoverishment of the blood, and renders 
the nervous system more impressible. Facts mentioned by Reid and 



440 INTERNAL CONVULSIONS. 

others show conclusively the influence of premature weaning, and of indi- 
gestible or otherwise improper aliment, in the production of this disease. 

The causes enumerated above are for the mo^t part predisposing ; occa- 
sionally they are the only apparent causes, since this disease sometimes 
occurs when the child is perfectly tranquil, even in the midst of quiet 
sleep, or when it is at rest in its mother's arms. In other cases, and more 
frequently, there is an exciting cause, often trivial. Anything that re- 
quires exertion on the part of the infant, or that excites strong emotions, 
may be a direct cause, as anger, or any of the violent passions ; so may 
even coughing, or, in rare instances, attempts to swallow. One author 
has known it to occur from excitement produced by examining the throat 
with a spoon. In a case in my practice, hereafter related, it occurred 
whenever the infant cried violently. It appears from the above facts that 
the etiology of internal convulsions is very similar to that of eclampsia. 
The same spasmodic muscular contraction may occur from a variety of 
causes. 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this dis- 
ease, so far as ascertained, presents no anatomical characters, and must 
consequently be considered one of the neuroses. The lesions of the respi- 
ratory apparatus, observed at post-mortem examinations, are either due 
to the convulsions or are coincidences. Emphysema has sometimes been 
observed as a result, it is believed, of the spasmodic and irregular respira- 
tion. It was present in all of Herard's cases, and Rilliet and Barthez 
consider it common in those who die of this affection, although they did 
not observe it in any of their cases. Slight emphysema occurring in the 
upper lobes is, however, a common lesion in feeble infants, whatever the 
disease of which they die. Therefore its occurrence in internal convul- 
sions is probably more due to molecular change in the lungs, since these 
patients are cachectic, than to the irregular breathing, which is only 
momentary. 

In fatal cases of internal convulsions the blood is darker than usual, 
from an excess of carbonic acid ; the cavities of the heart and large ves- 
sels are sometimes engorged with blood ; but in other cases they contain 
no more than the normal amount. More or less passive congestion occurs 
in the internal organs ; and congestion of the cerebral vessels is sometimes 
such that transudation of serum occurs. 

Symptoms I have said that the symptoms vary according to the seat 

and function of the muscles which are affected. There is generally pre- 
vious ill-health. The child is drooping, and is sometimes restless for days 
before the disease appears. Finally, if the muscles of the glottis become 
affected, the peculiar crowing sound is heard now and then during inspira- 
tion. It is observed especially when the child is crying or is agitated. It 
may be loud and well-defined from the first, but in most patients it comes 



SYMPTOMS. 441 

on gradually, so that several days elapse before its full stridnlous charac- 
ter is developed. The attacks are more frequent and severe at night, in or 
after the first sleep, than in daytime. 

Under favorable hygienic conditions, the malady may pass off without 
becoming more serious. In other cases the paroxysms gradually increase 
in frequency and severity. The dyspnoea in the attack is such that the 
features are livid, the head forcibly retracted, and death seems imminent 
from apncea. In these severe paroxysms respiration often ceases entirely 
for a moment. When the spasm ends, a deep stridulous inspiration occurs, 
after which the breathing is natural. It has been stated that internal con- 
vulsions are often associated with those, usually tonic, but sometimes 
clonic, of the external muscles. In the tonic form, the thumbs are flexed 
across the palms of the hands, and sometimes are grasped by the fingers ; 
the great toes are adducted, and the other toes flexed. In severe cases, 
the hands, forearms, feet, and legs are also somewhat flexed and rigid. At 
first, the contraction of the external muscles is temporary, either corre- 
sponding with the internal spasm, or it is most intense at the time of the 
spasm, though commencing sooner and subsiding later. After a while, 
however, if the disease continues, the external contraction becomes more 
persistent. In severe cases, nearly every inspiration is accompanied by 
the wheezing sound, and the paroxysms of dyspnoea are excited by trifling- 
causes. Anything that suddenly disturbs the mind or body may bring on 
the attack, as anger, the impression of cold, or currents of air. Dr. West 
calls attention to the fact that an anasarcous condition is sometimes present, 
accompanied by albuminuria. 

If the convulsions affect other muscles, as the diaphragm or the pectoral 
and abdominal muscles, which are concerned in the respiratory function, 
while those of the larynx escape, respiration is irregular, or even suspended 
for a moment, but the stridulous laryngeal sound is absent, as there is no 
obstacle in the larynx to the entrance of air. In this form of the disease, 
the infra-mammary region may be strongly retracted during the paroxysm 
from tonic contraction of the diaphragm. In severe paroxysms, whether 
the spasm be laryngeal or diaphragmatic, consciousness is nearly or quite 
lost, the features may be pallid, or, if respiration be suspended, may be 
more or less livid. There is no fever in simple cases. In the paroxysm 
there is often relaxation of the sphincters of the bowels and bladder, with 
involuntary evacuations. 

The duration of the paroxysm may be a quarter, a half, or even a whole 
minute. Total suspension of respiration for even half a minute involves 
danger. In mild cases there may be but few paroxysms, and they slight. 
In other instances they occur in a severe form, almost daily for several 
weeks or even months. In the following case the muscles of the larynx 
were apparently not involved. The patient was scrofulous, and has since 
had scrofulous periostitis, with necrosis and exfoliation of the surface of 



442 INTERNAL CONVULSIONS. 

the tibia. At the time of the internal convulsions there was also a scor- 
butic or hemorrhagic cachexia. 

Case. — On the 28th of August, 1858, a German female infant, fourteen 
months old, nursing, and having eight teeth, was suddenly seized with 
clonic convulsions. Uniformly delicate and pale, she had been in her 
usual health till the age of twelve months, when she had a single con- 
vulsive attack, and from that date had remained well till August 27th, 
when, without any premonitory symptom, she had a stool consisting of 
almost pure blood, black and offensive. On the morning of the 28th a 
similar evacuation occurred, and another in the afternoon immediately 
preceding the convulsion. Pulse 128, after the convulsion ; surface cool 
and pallid ; flesh soft, but no emaciation. Turpentine was prescribed in 
two-drop doses every two hours, and laudanum in one and a half drop 
doses, repeated sufficiently to insure quietude. 

On the 29th the pulse was 152. At 1 P. M. she had a general convulsion, 
lasting about five minutes; in the evening she had an evacuation similar 
to those passed on the preceding day. The record for August 30th states: 
"Pulse from 150 to 160; up to this time has been playful, but is now 
drowsy, and, when disturbed, fretful ; manifests no desire for solid food, as 
before her sickness, but still nurses ; has taken up to this time thirty -two 
drops of turpentine. When she cries or frets, she has a spasmodic attack." 
This was the commencement of internal convulsions, with which this child 
was affected for several months. An opportunity was afforded of observing 
their character, for her excitement, when she was examined, was usually 
sufficient to produce them. After a succession of short expirations, res- 
piration ceased ; for a moment she was apparently insensible ; eyes closed ; 
face pale ; no frothing at the mouth. The return of consciousness and 
respiration was without any laryngeal rale ; and after the attack she seemed 
as well as before. No external convulsion and no evacuation of blood 
occurred after August 31st. 

There was gradual improvement in her health, but she continued for 
many months pallid and irritable, and subject to attacks of internal con- 
vulsions. On the 11th of April, 1859, when twenty-two months old, she 
had another attack of general convulsions. The record made on that day 
is : " Has had internal convulsions (one or more paroxysms) almost every 
day since last August, brought on usually by crying when she is corrected 
in any way, or her wishes are refused." Again, on December 1, 1859, it 
is stated : " Has grown considerably since the last record, and appears to 
have recovered, except that at long intervals the spasms still occur." She 
took a preparation of iron, but her recovery seemed to be due more to 
the growth and development of the body, and to hygienic than therapeutic 
measures. 

The general health in internal convulsions is more or less impaired, ex- 
cept in mild forms of the disease, in which the convulsive attacks soon cease. 
Pallor, or a sickly and cachectic aspect, irregular, usually constipated 
bowels, poor appetite, and moroseness or irritability of temper, are com- 
mon symptoms of severe and protracted cases. 

Diagnosis This disease is easily diagnosticated, unless when its symp- 
toms are masked by those of external convulsions ; it may then escape no- 
tice. Spasm of the glottis may be mistaken for spasmodic laryngitis, and 



TREATMENT. 443 

vice versd. In some of the published cases this mistake appears to have 
been made. Spasmodic laryngitis is, however, so different not only in its 
nature, but in its clinical history, that a differential diagnosis is not diffi- 
cult. It is an inflammatory disease, and is attended with febrile reaction 
and a sonorous cough ; it commences at night after the first sleep, and from 
exposure to cold — particulars in regard to which it contrasts with true 
spasm of the glottis. 

Prognosis — Modes of Death — Statistics show great mortality in 
this disease. Dr. Reid, in a monograph on " Infantile Laryngismus," 
states that of 289 cases which he collated, 115 died. Rilliet and Barthez 
met with one favorable case in nine unfavorable : and Herard, one in seven. 
If the paroxysms are mild, infrequent, and dependent on a cause which 
can be easily removed, recovery is probable with proper treatment. The 
cause may, however, be such, even when the spasm is mild, that the case 
is necessarily unfavorable ; as when it is due to disease of the cerebro- 
spinal axis. We should not, however, in any case consider the patient 
entirely safe, since grave symptoms may suddenly arise, so as to change 
entirely the prognosis. Long and severe paroxysms, with lividity of the 
face, and symptoms of suffocation, indicate an unfavorable result. The 
same should be predicted also if the infant gradually waste away, losing 
appetite and strength, especially if the face is pale and the pulse feeble. 

There are three modes of death in internal convulsions. The first is 
apnoea. The infant dies suffocated in the attack. Respiration is first 
arrested, and then the pulse ceases, and at the autopsy the lungs and the 
cavities of the heart are found engorged with dark blood. Death may 
also result from the state of the brain. In such cases, passive congestion 
of the brain occurs from obstruction to the return of blood from this organ 
to the heart and lungs ; and if this congestion is not soon relieved, serous 
effusion also occurs. Death results from the congestion, and consequent 
oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe at- 
tacks undermine the constitution ; the infant gradually grows pale and thin, 
and dies of inanition, or of some disease which this state induces. 

Treatment The treatment of internal convulsions has varied accord- 
ing to the theories which physicians have held in reference to its cause. 
Glandular enlargement is no longer regarded as a common cause, and 
therefore treatment directed to its removal is less frequently employed 
than formerly. The causes of internal convulsions are in part very similar 
to those of eclampsia, and the remedies employed in the one affection are, 
in a measure, appropriate in the other. That dentition is sometimes a 
cause, is usually admitted ; and two cases, one of which occurred in my 
practice, and the other was reported to me, clearly show the truth of this 
belief. The effect of dentition is especially observed in weakly infants, 
when several dental follicles are undergoing active evolution. Thus, in 



444 INTERNAL CONVULSIONS. 

one of the cases to which I refer, five teeth pierced the gums in the course 
of two weeks ; after which no convulsive attack occurred. If, therefore, 
the gums are swollen, the propriety of scarification should be considered. 

In all cases of internal convulsions a careful examination should be 
made, in order to detect any appreciable cause of nervous excitation. The 
condition of the digestive organs should be ascertained, and evacuants or 
other remedies prescribed if there is evidence of their derangement. 

Sometimes the alimentation of the infant is in fault. It is, perhaps, 
bottle-fed, and the stools have an unhealthy appearance. Attention 
should be given to the preparation of its food and the times of its feeding ; 
or, if it nurse, the mother or wet-nurse who suckles it should have plain 
but nutritious diet, live with regularity, and give the breast to the infant 
at regular intervals. If there is a torpid state of the intestines, Dr. Meigs 
recommends " castor oil and aromatic syrup of rhubarb rubbed up toge- 
ther, three parts of the former and five of the latter." A simple enema 
answers well in such cases, and, in debilitated infants, this is preferable 
to medicine administered by the mouth. If there be diarrhoea, and it 
persist after the requisite changes are made in regard to the diet, remedies 
calculated to relieve it, and which are detailed elsewhere, should be 
employed. Marshall Hall states that he has ordinarily succeeded in 
curing the disease by attending to the condition of the gums and digestive 
organs. 

Since rachitis is a not uncommon cause, the child should be examined 
in reference to the rachitic manifestations, and if they appear the treat- 
ment appropriate for rachitis is required. 

In pallid and cachectic infants, tonics are indicated. The elixir of Cali- 
saya bark in half-teaspoonful doses, three or four times daily, to an infant 
of one year, is an eligible preparation. The compound tincture of bark, 
or of gentian, or the two mixed, may be given instead of the Calisaya 
bark. The preparations of iron are sometimes to be preferred, as the citrate 
of iron and bismuth, citrate of iron and quinia, the syrup of iodide of iron, 
or the wine of iron. To an infant of one year the syrup may be given 
in doses of three drops, the citrates in one grain doses, and the wine in 
doses of one teaspoonful, three times daily. If the child is old enough, it 
may take iron in lozenges, as those of chocolate and iron. 

Antispasmodics, as assafcetida, valerian, and oxide of zinc, are often pre- 
scribed in this malady, but they are less efficacious than the general tonic 
measures which I have indicated. The salutary effect of bromide of 
potassium in eclampsia, and certain epileptiform attacks, certainly justifies 
the trial of this agent in internal convulsions, if they persist after the em- 
ployment of invigorating measures. 

Hygienic measures are of the utmost importance. The infant should 
reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 



TREATMENT, 445 

this simple expedient, when medicines have entirely failed. In the Lon- 
don Med. Gazette, Jan. 14, 1865, Mr. Robertson, of Manchester, relates 
five severe cases in which this malady was cared by exposure of the 
infants several hours daily to a cool atmosphere. These cases were 
treated in the winter months, and were kept out-door, even during strong 
winds. Mr. Robertson has records of forty cases, all occurring between 
December and April, while he has seen no case in the summer months. 
As the result of such extensive experience, this writer recommends " the 
free exposure of the infant out of doors, for many hours daily, to a dry, 
cold atmosphere, and if the air be dry, the colder the better." Dr. Mar- 
shall Hall's experience was similar. Says he : "The curative influence of 
change of air, and especially of the sea-breezes, is not less marked in this 
affection than in hooping-cough." Mr. Robertson recommends also, as 
part of the tonic treatment, "free sponging of the body every morning 
with cold water." In February, 1867, I attended a nursing infant, five 
months old, with internal convulsions, the paroxysms being attended with 
lividity of the face, and, at times, tonic convulsions of the limbs. Among 
the remedies employed was bromide of potassium, but more benefit ob- 
viously accrued from keeping the infant much of the time in the open air, 
than from the medicines employed. The disease passed off in six or eight 
weeks. 

Unless the cause is of such nature that it cannot be removed, the above 
hygienic and therapeutic measures will, in a large proportion of cases, be 
followed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. Dr. 
Hall recommends tickling the nostrils w r ith a feather, to produce respi- 
ration, or the fauces, to occasion vomiting, and thereby interrupt the 
paroxysm. Anything which produces a sudden and profound effect upon 
the system may abridge the attack. This was effected in one case, in the 
practice of Dr. C. D. Meigs, by applying a cloth wrapped around ice over 
the epigastrium and the lower part of the sternum. The chief danger 
during the attack is from congestion of the brain, with effusion of serum 
or extravasation of blood. If the attack is severe, and the features con- 
gested, so that there is evident danger of such a result, cold applications 
should be made to the head, derivatives used for the extremities — as sina- 
pisms, or mustard foot-baths — and the bowels should be speedily opened 
by enemata. 



446 CHOREA 



CHAPTER XIV. 

CHOREA. 

Chorea, or St. Vitus's or St. Guy's dance, is a neurosis, which is 
characterized by irregular and involuntary muscular movements, without 
loss of consciousness. The movements occur in the muscles of volition, 
and there is probably no one of them that may not be engaged, though 
some are more frequently affected than others. It is not known that any 
involuntary muscle is ever involved, though Sir William Jenner has ex- 
pressed the opinion that occasionally the papillary muscles of the heart 
are, so that, by their spasmodic contractions, they produce insufficiency of 
the mitral valve. This, according to him, affords explanation of the fact 
that, in certain instances, a mitral regurgitant murmur is heard, which 
disappears about the time that the external movements cease. It is rare, 
however, that a mitral regurgitant murmur, heard during chorea, ceases 
when the latter terminates, and it is not improbable that in such cases 
there is, after all, a lesion of the valve, due to recent endocarditis, whether 
of a rheumatic or other origin. For a valve may be so thickened by 
recent inflammation as to cause a murmur, and after a few weeks or 
months the infiltrating substance be so absorbed that the murmur is no 
longer audible. If we admit the fact that cardiac bruits occasionally 
appear and disappear with chorea, this explanation seems to me more 
plausible than that of Jenner. Hillier says, in reference to this subject : 
" My own experience leads me to doubt the existence of dynamic apex 
murmurs in chorea, that is to say, murmurs produced in hearts entirely 
free from organic change. If such murmurs ever occur, they are certainly 
rare. Organic murmurs of the heart, on the other hand, are common in 
chorea, and I am inclined to believe that organic disease of the heart often 
exists in chorea when there is no murmur." We shall see that this opinion 
is correct, by a case presently to be related. Hillier also calls attention 
to the fact that choreic movements are irregular ; but a cardiac bruit 
occurring regularly and uniformly, if not due to organic disease, would 
require rhythmical contractions of the papillary muscles to produce it. 

In the class of children's diseases in the Bureau for the Relief of the 
Outdoor Poor in New York city, 6986 children were treated in the two 
years and three months, ending with March 31st, 1877. Of these cases 
82, or one in every 207, had chorea. The patients were all under the 
age of fifteen years. Statistics published by observers in Europe show 
that the relative frequency of this disease is probably about the same in 



causes. 447 

the large European cities as in New York. Thus, according to Hillier, 
amongst 122,621 out-patients treated at the Hospital for Sick Children, 
in London, 406, or 1 in 322, had chorea; while of the in-patients 174 in 
5585, or 1 in every 32, were choreic. In the Parisian Hospital for Sick 
Children, of 84,968 admitted in twenty-one years, 531 had chorea, or 1 
in every 161. 

Age Chorea may occur at any period of life, but a large majority of 

the cases are in childhood. It is rare in infancy, and it rarely begins 
after puberty. Under the age of five years the proportionate number 
diminishes, as we approach the time of birth. The youngest in the 
statistics of Hillier was three months. In 1870, in the Bureau for the 
Outdoor Poor, a child was presented for treatment, who the mother said 
had had chorea from birth, and in 1877 I treated a young woman with 
severe general chorea, who, repeatedly questioned, uniformly said that 
she had had the disease, without any assignable cause, from the first week 
of her life, and her friends corroborated the statement. The following 
table exhibits the relative frequency of chorea at different ages : — 

6 years 

and 6 to 10 10 to 15 
under, years, years. 

Children's Hosp., Lond., Hillier, none over 12 years admitted 81 237 104 

M. Rufz 10 61 118 

Bureau for Outdoor Poor (prior to 1875) .... 2 26 16 

Under 3 3 to 5 5 to 10 10 to 15 
years, years, years, years. 

Bureau for Outdoor Poor (since January 1. 1875) . 13 51 14 

M. See collected the statistics of 531 cases occurring in the Children's 
Hospital, Paris, and from them concludes that the maximum frequency of 
chorea is between the sixth and tenth years. Only twenty-eight of his 
cases were under six years, the remainder, 503, occurring between the 
sixth year and puberty. 

Causes — The profession are nearly agreed in regard to certain causes 
of chorea, while there is a diversity of opinion in reference to others. It 
is admitted that in a large proportion of cases there is a neuropathic state, 
which antedates and predisposes to chorea. This state is often manifested 
in the family history by a proneness to affections of the nervous system, 
and in the individual by a highly excitable state of the emotions, so that 
he evinces joy, grief, or anger, from slight causes. 

All writers admit that there is often an inherited predisposition to chorea. 
In 27 of 48 cases of chorea, Radcliffe found that father, mother, brother, 
or sister had been or was the subject of one or other of the following dis- 
orders : paralysis, epilepsy, apoplexy, hysteria, or insanity. The children 
of parents who when young had chorea, or who exhibit proneness to ail- 
ments of the nervous system, are more liable to chorea than other chil- 
dren. Hence the fact sometimes observed, of different children in the 



27 to 


73. 


138 to 


393. 


50 to 


94. 


276 to 


499. 



448 CHOREA. 

same family becoming affected with chorea when they attain the age at 
which this disease ordinarily occurs. In one family in my practice, three 
girls at different times were affected. 

Sex The emotions are strong in girls, since in them the nervous 

system predominates, while the muscular power is weaker than in boys. 
Hence a partial explanation of the fact which statistics fully establish, that 
the proportion of choreic boys to girls is about in the ratio of one to two 
and a fraction. I have remarked, in this city, the large proportion of cases 
in school-girls between the ages of six and twelve years ; the severe dis- 
cipline and confinement of the public schools no doubt increasing the 
strength of the emotions, and weakening the control of the will over the 
muscles. 

Proportion of Males to Females. 

Hughes's Digest of Cases in Guy's Hosp., 1846. 

M. See. 

Outdoor Department, Bellevue. 

Children's Hosp., Lond. West (Lumleian Lect.). 

481 to 1059 = 1 to 2.15. 

Uterine Irritation The peculiar changes occurring in the female 

at puberty constitute an important cause. Hence another reason of the 
excess of female cases. Dysmenorrhoea and pregnancy are causes of a 
large proportion of cases in the first years of puberty. In the male, on 
the other hand, the changes of puberty do not appear to increase the 
liability to the disease, directly or indirectly, and male cases, after the 
age of twelve years, are comparatively rare. Radcliffe states {Reynolds' 's 
System of Med.) that after the ninth year, females are more liable to chorea 
than males, in the proportion of 5 to 2 ; while before the ninth year, the 
two sexes are equally liable to it. Carefully prepared statistics, however, 
notwithstanding the high authority of Radcliffe, show a preponderance of 
girls under the age of nine years, though not as great as over that age. 
In the Outdoor Department at Bellevue, of 35 patients under the age of 
ten years, 22 were girls, while of 20 from the age of ten years to sixteen, 
15 were girls. 

According to West (Lumleian Lect.), in 775 children with chorea, 
under the age of ten years, treated in the Lond. Children's Hosp., 64 per 
cent, were girls. 

Anaemia Among the most common predisposing causes of chorea is 

anaemia. It is present in so large a proportion of cases, exhibiting itself 
by pallor of the countenance and other characteristic signs, that medicines 
designed to improve the quality of the blood are among the most valued 
remedies. The peculiar neuropathic state already alluded to, which needs 
only a slight additional cause for the development of chorea, is, no doubt, 
largely dependent on impoverishment of the blood, if it is not sometimes 



RHEUMATISM. 449 

due entirely to it. Among the poor of a large city like Xew York, or in 
hospital practice, the proportion of anamiic cases of chorea is, for obvious 
reasons, much larger than would appear from general statistics. 

Rheumatism Dr. Copeland, M. Bouteille, and afterwards M. Germain 

See, in a more extended monograph, directed the attention of the profession 
to rheumatism as a cause of chorea. Subsequent observations have estab- 
lished the fact that rheumatism, or the rheumatic diathesis, is so frequently 
present that it obviously sustains an important relation to chorea, though 
in what manner is not fully ascertained. This relation between the two 
is more frequently observed in some countries than in others. In England 
and France, so large a proportion of choreic patients present the history 
of rheumatism either in themselves or family, that certain physicians of 
these countries believe that rheumatism is the most common cause of the 
disease. In Germany, on the other hand, according to Romberg, in the 
majority of cases no relation can be tracted between chorea and rheuma- 
tism, and the statistics of this city, and I think of this country, correspond 
with those in Germany. 

Various theories have been promulgated in explanation of the relation- 
ship of the rheumatic and choreic diseases. It has been suggested that 
chorea is due to rheumatism of the brain or spinal cord. This is simply 
an hypothesis, the truth or falsity of which can only be ascertained by 
carefully conducted necropsies ; but the theory appears improbable in view 
of all the facts. Another theory attributes chorea to the state of the blood 
which is present in those having rheumatism or the rheumatic diathesis, as 
well as in certain other conditions. This theory is enunciated by Dr. Ogle, 
as follows : " Recognizing the frequent existence of these fibrinous deposits 
or granulations on the heart's valves in chorea, I should be much inclined 
to look upon these post-mortem appearances rather as results of some 
antecedent general condition of the blood, common also to the choreic 
condition. It is very freely recognized that this affection is frequently, in 
some way or other, connected with that condition of blood which obtains 
in what we call anosmia, or that existing in rheumatic constitutions. In 
both of these states we know that the fibrin of the blood is much in excess 
(as also it is in pregnancy, another condition looked upon as obnoxious 
to chorea) ; and in these states we know that the fibrin with which the 
blood is surcharged is very prone to be readily precipitated, either owing 
to its superabundance, or from other obscure and acquired properties . . . 
upon the heart's walls or valves. May not this hyperinosis be the ex- 
planation of the coincidence alluded to?" (^British and Foreign Med.- 
Chir. Rev., January, 1868) — namely, the occurrence of chorea in those 
affected with rheumatism. Others still hold that chorea is the result of 
the heart disease, and not directly of rheumatism, occurring when the 
heart is affected from other causes, as well as when the lesion has a rheu- 
matic origin. This theory is plausible, and probably to a certain extent 
29 



450 CHOREA. 

correct. Heart lesions, observed in children, result from scarlet fever in 
a considerable proportion of cases, though, it is true, the endocarditis and 
pericarditis of scarlet fever are believed often to have a rheumatic origin, 
occurring, in some instances, from scarlatinous rheumatism, but in other 
cases from scarlatinous uraemia. Occasionally, also, the heart disease ap- 
pears to have occurred independently of both rheumatism and scarlet 
fever. Thus in a fatal case of chorea with valvular disease, related to the 
London Pathological Society, April 6th, 1869, the child was always healthy 
up to the present illness (chorea), and there was no history of rheumatism 
in the family. The more observations accumulate, the more important 
does heart disease in itself appear as a cause of chorea. In nearly all 
recorded cases of fatal chorea, which were supposed to be due to rheu- 
matism, and in which post-mortem examinations were made, endocardial 
and usually valvular disease has been found. We shall see that certain 
eccentric causes of irritation aid in producing chorea, and may not the 
valvular disease, or the endocarditis which causes the valvular lesion, 
operate in a similar manner as a cause? We know that in the adult 
severe cardiac disease often profoundly affects the nervous system, perhaps 
in consequence of the irregular and embarrassed circulation ; and certainly 
in the child a similar cause would be likely to produce a more decided 
effect. 

But there is an ingenious theory which attributes chorea to minute 
emboli detached from vegetations on the valves, and arrested by capillaries 
in the corpora striata, or other portion of the cerebro-spinal axis. Since 
attention was directed to this matter, emboli have been found in one case 
in the medulla oblongata, although this portion of the spinal axis appeared 
healthy to the naked eye. Further observations are necessary in order to 
determine how much truth there is in this theory; but it seems probable, 
for reasons to be stated, that if capillary embolism does cause chorea, it is 
only in a limited number of cases, and that therefore those British ob- 
servers who regard it as the common cause, have been led into error by 
the large proportion of choreic cases which are complicated by valvular 
lesions in their climate. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there 
are no vegetations, or rather appreciable lesions, which could give rise to 
emboli. Secondly. Most patients recover, and some speedily, by treat- 
ment, which we would not expect if the cause were embolism. Thirdly. 
Embolism is not infrequent in the cerebral vessels of the adult, without 
the occurrence of chorea. Indeed, the conditions which produce embolism 
are much more common in adults than in children, while the reverse is 
true as regards the liability to chorea. Fourthly. Dogs sometimes have- 
chorea, but the injection of minutely divided fibrin or other substance in 
the veins of the dogs is not followed by chorea as one of the phenomena. 



RHEUMATISM. 451 

Fifthly. Were capillary emboli the cause, we would expect to find an 
occasional embolus in the larger vessels of the brain, so as to be appre- 
ciable to the naked eye ; but I find no examples of this in all the recorded 
autopsies which I have been able to consult. Moreover, it seems improb- 
able that capillary embolism, when producing no lesion appreciable to the 
naked eye, would so arrest the circulation, and disturb the function of the 
brain or spinal cord, as to cause chorea, for the ill effects of such an ob- 
struction would be likely to be obviated by the numerous anastomoses. 

In 1877 the unusual opportunity occurred, in my asylum practice, of 
determining whether there are any fixed anatomical characters in the 
cerebro-spinal axis in chorea ; in other w r ords, whether chorea is a neurosis, 
as we have designated it in our definition, and the case is so interesting in 
other respects that I will relate it entire. 

Charles, a foundling, born Oct. 15th, 1874, was received in the N. Y. 
Foundling Asylum soon after his birth. When two weeks old he w^as 
removed to a family in the city to be wet-nursed. His health continued 
good till the age of three months, when he had bronchitis and keratitis, 
the former mild, and lasting only a few days, but the latter continuing 
nearly two months, being attended by moderate injection of the conjunc- 
tiva, with some purulent discharge, which caused adhesion of the eyelids 
during sleep. From this time he remained well, w r ith the exception of a 
slight attack of dysentery, till the age of about nine and a half months, 
when he began to have febrile symptoms. In the morning hours he seemed 
in tolerable heath, but at midday, or a little later than midday, of each 
day, he was observed to have slight irregularity or embarrassment of 
respiration, and lividity, with coolness of the extremities, which state, 
supposed at the time to be the algid stage of a somewhat irregular inter- 
mittent fever, lasted from one to two or three hours, and was succeeded by 
febrile movement, which continued during the remainder of the day ; some- 
times the fever abated in perspiration. 

On August 4, 1875, a few days after the commencement of these irre- 
gular febrile symptoms, Charles was brought to the dispensary of the in- 
stitution for treatment, and Dr. Reid, who w r as on duty that day, carefully 
examined the case, and prescribed the sulphate of quinia. This medicine 
continued a few days relieved the symptoms, but every four to six weeks, 
for more than a year, these febrile attacks returned, and were uniformly 
relieved by the same medicine. In other respects the patient had the 
usual health. 

On or about February 1, 1878, the nurse noticed that Charles had what 
she designated "spells of trembling," in which he seemed excited and 
feverish, and which were sometimes attended by or followed by perspira- 
tion. In the course of another week the irregular muscular movements 
became more marked and constant, and they increased in severity till near 
the time of the admission of the patient into the asylum, about March 1st. 
The nurse had noticed in February slowness and some difficulty of micturi- 
tion, and Dr. Reid examined him with a catheter for calculus, and also his 
prepuce for any source of irritation, but nothing abnormal was discovered, 
either in the condition of the bladder or the external organs. In the lat- 
ter part of April, the chorea had become so severe, that irregular muscular 
action occurred in all the limbs, and in the muscles of the eyes, producing 



452 CHOKEA. 

such grimaces and contortions with strabismus, that the woman with whom 
he was boarding became alarmed, and returned him to the asylum stating 
that he had become crazy. 

On March 12th my attention was first called to this child, when I made 
the following entry in my note-book : " Family history unknown ; no his- 
tory of rheumatism in patient's case, he may and may not have had it ; 
heart sounds normal ; pulse 104 ; all the limbs and the muscles of the face, 
eyes, and eyelids involved in choreic movements, which continue con- 
stantly except during sleep. The patient cannot walk or stand without 
support ; appetite good, apparently better than in health, for he eats every 
kind of food handed to him, and carries the food with his own hands to his 
mouth, although these movements are very irregular and jerking. Three 
drops of Fowler's solution ordered after each meal. 

March 17th. — Condition not much changed, but perhaps slight im- 
provement ; in addition to other choreic movements the eyes twitch 
spasmodically ; pulse 84 ; temperature 98-J° ; bowels regular ; no cough ; 
appetite good. Increase medicine to five drops. 

30^. The urine examined since the last record was found very pale 
and abundant ; its specific gravity low, 104, without albumen. When an 
equal quantity of nitric acid was added to it, after twelve hours crystals 
of nitrate of urea occupied about one-half of the volume of the urine. The 
patient's sleep is quiet, but the choreic movements recommence as soon as 
he awakens, but in a milder form ; is able to walk without support, but 
with unsteady gait. My term of service ended March 31st. On the fol- 
lowing day, laryngo-tracheitis was suddenly developed, ending fatally in 
forty-eight hours, at the age of two years five and a half months. 

Autopsy, April 4th. Slight oedema about the aperture of the glottis ; 
general and intense redness of mucous membrane of larynx, trachea, and 
bronchial tubes, as far as they can be traced, posterior portions of lungs 
greatly congested. The heart, lungs, brain, with one eye attached to it by 
optic nerve, and the entire spinal cord were sent to Prof. Francis Delafield 
for microscopic examination. They were, as soon as removed, placed in 
a solution of bichromate of potash. The following is a brief statement of 
the examination, which was thoroughly made. 

Microscopic Appearances. By Prof. Francis Delafield. Brain — 
presented no change apparent to the naked eye, except a considerable 
degree of congestion. It was hardened in bichromate of potassas and 
chromic acid. Minute examination of the convolutions of the brain, the 
large ganglia, the cerebellum, the pons Varolii, and the medulla oblongata 
showed nothing except a uniform filling of the vessels with blood, as if 
they were injected. There were no apoplexies,, no changes in the walls of 
the vessels. 

Spinal cord — appeared to be entirely normal. 

The Heart The auricles and ventricles were of normal size. The 

aortic valves were atheromatous, and somewhat rigid ; the mitral valves 
were thickened and insufficient ; the endocardium of the left ventricle was 
thickened. 

The Lungs The capillaries in the walls of the air-vesicles were dila- 
ted, and there was an increase of epithelial cells within the air vesicles. 

In this case there seemed to be no lesion associated with the chorea 
except the organic disease of the heart, and the changes in the lungs, 
secondary to this condition of the heart. 

The above microscopic examination was made with sufficient minute- 



FBIGHT — IMITATION. 453 

ness, and it is seen that no emboli were discovered, and no lesion of the 
cerebro-spinal axis except congestion, which was attributable to the mode 
of death, namely, by obstructed respiration. Moreover it will be recol- 
lected that there were no cardiac bruits, and apparently not sufficient 
roughness of the edge or surface of the valves to cause precipitation of 
fibrin, which would be necessary in order that emboli should form. 

Fright A not infrequent exciting cause of chorea is sudden and pro- 
found emotion, especially fright. All statistics give fright as the cause of 
a certain proportion of cases, though there are usually other potential 
co-operating causes, as anaemia or valvular disease. Fright was stated as 
the cause of chorea in 31 of the 100 cases occurring in Guy's Hospital, 
reported by Hughes, or in nearly one in three. But the statistics of other 
observers do not give so large a proportion of cases originating in this 
way. Chorea may commence within a few hours after the fright, or not 
till the lapse of several days (eight or ten). If several weeks have passed 
since the fright, as in some reported cases, the chorea is probably due to 
other causes. In rare instances, chorea is said to have been caused by 
sudden and excessive joy. 

Imitation Under unusual circumstances, especially in a state of great 

mental excitement, imitation has been known to cause a form of chorea. 
Hecker describes an epidemic of it, occurring in the middle ages, and 
spreading through villages. In modern times it is rare that chorea 
originates from this cause, nevertheless occasional examples have been 
recorded. 

But the disease which occurs from imitation differs from the ordinary 
form, and has been termed chorea major ; while the chorea which is 
the subject of this article is sometimes designated, in contradistinction, 
chorea minor. 

In chorea major the patient leaps, dances, or whirls like a top. It has 
its origin commonly in religious excitement, and spreads by imitation 
almost in the manner of an infectious disease. The epidemic of the 
middle ages was a chorea major. I have not been able to find any ac- 
count of cases spreading by imitation, in modern times, which were not 
examples of the same form of chorea. Thus in the Edin. Jour, of Med. 
and Surg, for July, 1839, there is a clear description of chorea major, 
occurring successively in five children in the same family. Dr. Dewar, 
the attending physician, states that one of the children whom he was 
called to see was sitting near the fireplace, when her head dropped on her 
chest, and she appeared to doze some minutes. In the mean time the res- 
piration became a little accelerated, the face altered and flushed, the eyes 
wild. In less than one minute she bounded from one extremity of the 
apartment to the other, leaping over chairs, a chest, and then throwing 
herself upon the floor ; she attempted to stand upon her head, rolled 
upon the floor, and then, rising, ran with extreme swiftness in the room, 



454 CHOREA. 

till she finally fell again on the floor, where she remained motionless some 
minutes. Then, recovering, she noticed those who surrounded her, and 
asked of her sister a toy, which she had allowed to fall. The whole 
paroxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major differ materially from those 
of chorea minor, and it is a question whether it should have the same 
generic name. It is a curious and interesting disease in its psychical and 
pathological aspects, but it is so rare in modern times that a knowledge of 
it is of little practical importance. 

Intestinal Irritation — In rare instances intestinal worms cause 
chorea, though in these cases there have usually been some co-operating 
causes. The following is an example, related by Mr. Ogle (Lond. Medico- 
Ghir. Rev., Jan. 1868) : " Ellen L., 9 years old, had been under treatment 
about a month, with chorea, rheumatism, and worms. She had not slept 
in four days, and there was constant spasmodic movement of the body 
and face. Her general condition was very unpromising. As she had 
passed portions of a tapeworm at intervals during the last three months, 
one drachm of the oleum filicis maris was administered in mucilage, which 
caused the expulsion of the entire worm. From that time she fully and 
rapidly recovered from the chorea, though a mitral murmur remained." 

Lesions of Brain and Spinal Cord Although we reject the theory 

that cerebral emboli are the common cause of chorea, and believe that in a 
large majority of cases there are no cerebro-spinal lesions, nevertheless ex- 
periments, and also occasional cases, establish the fact that if not true 
chorea, at least choreiform movements now and then result from a struc- 
tural affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain 
portions of the cerebro-spinal axis, as the corpora quadrigemina, crura 
cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla 
oblongata, and the upper portion of the spinal cord. Pressure on the 
projecting part of the medulla oblongata of an acephalous monster also 
causes convulsive movements. At the meeting of the New York Academy 
of Medicine, April 20th, 1871, Professor Post related the case of a child 
who Avas struck with a billet of wood, over the occiput, and chorea fol- 
lowed, due, in all probability, to the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result from 
traumatic injury of certain portions of the nervous centres, may they not 
also occasionally occur from lesions of tile same parts produced by dis- 
ease ? Sir Benjamin Brodie relates the case of a choreic girl, dying in St. 
George's Hospital (London Lancet, Dec. 19th, 1840), in whom, after a 
careful post-mortem examination, the only morbid appearance observed 
was a tumor the size of a hazelnut, connected with the pineal gland. Dr. 
Broadbent described another case before the London Pathological Society 



ANATOMICAL CHARACTERS. 455 

(vol. xiii. page 246, Transactions), in which a tumor was found arising 
from the centre of the spinal cord ; and Chambers one in which tubercles 
were imbedded in the cord. Romberg quotes from Frerichs a case in 
which the medulla oblongata was pressed upon by an enlarged odontoid 
process; and Dr. Aitken (^Glasgoiv Med. Jour., vol. i.) one in which the 
specific gravity of the thalamus opticus and corpus striatum was greater 
on one side than on the other. Rilliet and Barthez relate other similar 
cases, and add : " We may conclude, from these different cases, that there 
exist two species of chorea : the one essentially a simple neurosis, while 
the other depends on an alteration of the encephalo-rachidian system. 
In a word, it is of chorea as of convulsions, that it is sometimes idiopathic, 
sometimes symptomatic." Still, the cases in which it is symptomatic are 
so few, that it is proper to consider chorea, as it ordinarily occurs, one of 
the neuroses until the microscope detects some anatomical cause in the 
cerebro-spinal system of which we are now ignorant. 

Anatomical Characters We have seen that chorea has no cer- 
tain anatomical characters. Lesions are sometimes present, which pro- 
bably sustain a causative relation to the disordered muscular action, and 
others are sometimes observed which are neither a cause nor result, their 
presence being a coincidence. But there are two lesions which, though 
often absent, have been observed in so large a proportion of fatal cases 
that they are justly regarded as an occasional result when chorea is severe. 
Dr. Hughes, of London, collected records of the post-mortem appearances 
of 14 cases, with the following result as regards the cerebro-spinal axis: 
Brain, 14 cases: healthy, 4 cases; only congested, o cases; softened in 
part or entirely, 6 cases (some of these also congested). In some of these 
cases those occasional results of congestion, namely, transudation of serum 
and extravasation of blood, in greater or less quantity, were also observed. 
Spinal cord : healthy, 3 cases ; congested, 2 cases (one slightly, in the 
other the engorged vessels were large and numerous) ; softening in medulla 
oblongata, 1 case ; softening opposite fourth and fifth vertebrae, 12 cases. 
In one there was soft, in another firm adhesion of the spinal meninges, 
and in one it is stated that the rachidian fluid was opaque. Of sixteen 
fatal cases of chorea occurring in St. George's Hospital, " congestion 
(more or less complete) of the nervous centres (brain or spinal cord, or 
both) was met with in six cases." There was softening of certain parts 
of the brain in one case, and of the spinal cord in another. (Ogle, Brit, 
and For. Medico-Chir. Rev., Jan. 1868.) Other statistics of the anatom- 
ical character of fatal chorea correspond, in the main, with those of 
Hughes and Ogle. These lesions are probably not present in ordinary 
cases, occurring only when the choreic movements are so severe that the 
patient is deprived of needed repose, and the important functions of the 
economy, as the circulation and nutrition, are seriously disturbed. 

The post-mortem examination of other parts besides the cerebro-spinal 



456 CHOREA. 

axis furnishes a negative result, if we except such affections as have been 
aeertained to act as causes of chorea. What portion of the nervous centre 
is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. 
Brodie {London Lancet, Dec. 19, 1840), consider chorea a disease of the 
nervous system generally, while others have attributed it to disease or dis- 
order of a certain part, as the corpus striatum, cerebellum, etc. Finally, 
it is stated that, in late experiments on choreic dogs, the movements do 
not cease when the spinal cord is severed from the brain, nor also on di- 
vision of the posterior roots of the spinal nerves. (Legros et Onimus, 
Rech. sur les mouvements choreiformes du chien, Acad, des Sci., 9 Mai, 
1870, Lyons Med. Jour., June 5, 1870.) In these cases, therefore, the 
part of the axis which is in fault would appear to be solely the spinal 
cord. 

Symptoms Chorea is partial or general. It is partial when it affects 

a few muscles, or groups of muscles, as those of one arm, the face or neck, 
or of one eye. It is designated general, when all the limbs, and certain 
of the muscles of the face and trunk, are involved. Statistics show that 
partial chorea occurs more frequently on the left than on the right side, 
and in general chorea the movements on the left side are apt to predomi- 
nate. The commencement is usually gradual. Even when finally chorea 
becomes general, certain muscles only are affected in the commencement 
in ordinary cases. The child in whom this disease is about to begin is 
observed to be fretful and impatient from slight causes, and the irregular 
muscular action at first is apt to be misunderstood by the parents, who 
reprimand him for his supposed fidgety habit. In exceptional instances, 
especially when the cause is a sudden and profound emotion, the com- 
mencement is abrupt, and the disease is severe and general from the first. 

In a majority of cases the muscles which are primarily affected are those 
of the face, neck, fingers, or hand on the left side. Sydenham erred, 
unless the clinical history of chorea has changed during the last two cen- 
turies, when he stated as the common fact that a tottering gait is its first 
manifestation ; but now and then such a case does occur. Wherever the 
choreic movements first appear, other muscles are soon involved, so that in 
the course of a few weeks, sometimes of a few days, all the muscles that 
participate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, but less 
forcibly and rapidly than in eclampsia, and the movement is partly con- 
trolled by volition. This produces an unsteady and tremulous action of 
the part, whether a limb, the neck, or face; which at once arrests atten- 
tion, and indicates the nature of the disease. The result is similar, as 
regards the muscular action, whether the patient wills a movement, or 
attempts to control those which chorea produces. 

If the case is of ordinary severity, the movements continue with but mo- 
mentary intermissions, except during sleep, when they ordinarily cease. In 



SYMPTOMS. 457 

grave cases patients are often deprived of the proper amount of sleep, in 
consequence of the severity and persistence of the muscular action, and in 
exceptional instances, especially when the result is fatal, the movements 
continue in sleep, but the sleep is not sound, and is frequently interrupted. 
In profound sleep, the muscles are probably always in repose. 

The older writers have left us graphic descriptions of those diseases 
which have striking external manifestations, though often with somewhat 
of exaggeration. Sydenham says of chorea : " The patient cannot keep 
it (his hand) a moment in the same place ; whether he lay it upon his 
breast, or any other part of his body, do what he may, it will be jerked 
elsewhere convulsively. If any vessel filled with drink be put into his 
hand, before it reaches his mouth, he will exhibit a thousand gesticula- 
tions, like a mountebank. He holds the cup out straight, as if to move 
it to his mouth, but has his hand carried elsewhere by sudden jerks. 
Then, perhaps, he contrives to bring it to his mouth, and if so, he will 
drink the liquid off at a gulp, just as if he were trying to amuse the spec- 
tators by his antics !" 

In severe general chorea a similar description is applicable to the move- 
ments of the legs and features. Grimaces and distortions of the features 
occur, while the gait is halting and unsteady, or it is impossible to walk, 
and the patient lies or sits. The speech is slow, thick, and indistinct, in 
consequence of the muscles of the tongue and larynx becoming engaged, 
and even mastication and deglutition are rendered difficult. The imper- 
fect speech in chorea is attributed partly, however, to the impairment of 
the mental faculties. Chorea, except in mild cases, is accompanied by 
other symptoms referable to the nervous system. More or less impairment 
of the mental faculties occurs in severe and protracted chorea, exhibiting 
itself in dulness or apathy. The countenance sometimes presents in ag- 
gravated cases almost the appearance of idiocy. The muscles, instead of 
becoming hypertrophied, and more powerful by their frequent contraction, 
grow softer, more flabby, and weaker. Indeed, a partial paralysis some- 
times results, so that a degree of numbness is experienced in the affected 
part, and the limb when raised cannot be sustained. Pain is not a symp- 
tom of chorea, but fugitive rheumatic or neuralgic pains are sometimes 
experienced. Derangement of the digestive function, exhibited by a poor 
or capricious appetite, constipation, etc., are common. 

The urine of choreic patients has been examined by Drs. Walsh, Ford, 
Bence Jones, Handheld Jones, Radcliffe, and others, and its elements 
have been found in most cases to vary from their normal quantity. Dr. 
Handheld Jones read a paper before the Clinical Society of London, in 
1871 {London Lancet, July, 1871), on two cases of chorea in which he 
had made careful chemical analyses of the urine, with the following re- 
sult : During the height of the disease the amount of the urine was much 
in excess of what it was when the disease had ceased ; the amount of 



458 CHOREA. 

urea excreted during the choreic period was enormous; the amount of 
phosphoric acid excreted when the choreic symptoms were at their maxi- 
mum was excessive, but the quantity was less than the average during 
convalescence ; a moderate amount of uric acid during the disease, but 
none upon recovery. 

Prognosis — Course — Chorea, though obstinate and often incurable 
in adults, usually terminates favorably in children in three or four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, which 
is certainly shorter than the average duration in this country, except as 
the disease is materially abridged by treatment. The same author states 
that it may continue only a few days, as he has observed in cases which 
occurred during convalescence from scarlet fever. But tremulousness of the 
muscles occurring in the state of weakness following a grave disease, and 
abating as the general health is restored, I should not consider as properly 
choreic, any more than that occurring from over-fatigue. As the choreic 
movements gradually increase in the initial period till a certain maximum 
is reached, so their decline is gradual. There are temporary variations 
also throughout the disease as regards the extent of the movements, which 
are aggravated by mental excitement, bodily fatigue, certain functional 
derangements, especially of digestion, and sometimes from causes which 
are not apparent. 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different, and even injurious, modes of treatment, there are excep- 
tional cases. Romberg relates the history of a patient who died at the age 
of seventy-six years, having had chorea since the age of six years. In 
chorea limited to a few muscles, or a group of muscles, the prognosis is 
more doubtful than when it affects a large number, since in the former 
case the cause is more apt to be some lesion of the cerebro-spinal axis. 
Thus chorea involving only certain muscles of the neck or of the eyes is 
sometimes due to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first in all proba- 
bility strictly a neurosis, but of a protracted and grave character, may give 
rise to a central organic disease. This is the course of most of the fatal 
cases, congestion, softening, or other lesion occurring over a greater or less 
extent of the nervous centres. Radcliffe has known cerebral meningitis 
to supervene in two instances. With the occurrence of a lesion of the 
cerebro-spinal axis new symptoms arise, such as headache, convulsions, 
delirium, and paralysis, and the choreic movements cease or continue, 
according to the nature of the lesion. 

Chorea, like certain other diseases, either of a nervous character, or 
having a nervous element, is more or less modified by intercurrent inflam- 
matory and febrile affections. The oft-quoted expression from Hippo- 
crates, febris accedens solvit spasmos, observations show to be founded in 
fact, the most frequent example of which occurs in pertussis. In chorea 



TREATMENT. 459 

the movements, as a rule, are either rendered milder or they cease as long 
as the febrile excitement continues ; but there are exceptions, and the 
subsequent course of the disease is not modified. 

Diagnosis This is not difficult in ordinary cases. The irregular 

movements, with consciousness preserved, enable us to make a diagnosis 
at sight. In its commencement, and when it continues in an unusually 
mild form, chorea might be overlooked by the physician, as it often is by 
the parents, the movements being attributed to a fidgety habit ; but medi- 
cal advice is seldom sought till the movements are so pronounced that it 
is impossible to err, except through gross ignorance or carelessness. 

It is important to determine when chorea merges in an organic disease, 
and also whether there is a local cause of the chorea. A careful and 
intelligent study of the symptoms and history of the case is requisite in 
order to a correct diagnosis in these particulars. 

Treatment. Regimenal. — As chorea in a large proportion of cases 
occurs in a state of ansemia, and the vital forces are ordinarily more or 
less reduced, obviously the regimen should be such as invigorates the sys- 
tem. Fresh air and outdoor exercise, active or passive, according to 
circumstances, with the avoidance of undue excitement, are requisite ; 
and the diet should be nutritious, but plain and unirritating. The various 
functions should be preserved so far as possible in their normal state. In 
exceptional instances, when the choreic movements are violent, the patient 
should lie in bed, and the muscular action, if so constant and excessive as 
to deprive him of the requisite sleep, should be restrained by light and 
well-padded splints. 

Medicinal — Sometimes among the co-operating causes is one of a local 
nature, which is susceptible of removal, as a carious and painful tooth, 
intestinal worms, etc., and measures calculated to effect this are obviously 
required. Allusion has already been made to a case in which the employ- 
ment of the oleo-resina filicis, and the expulsion of a tapeworm, effected 
a speedy cure. 

The remedy which has been most employed in chorea, and which in 
consequence of the anasmia is plainly indicated in a large proportion of 
cases, is iron. It does not interfere with the employment of other remedies 
which have a more specific effect. Nearly all the ferruginous preparations 
have been prescribed in different cases with benefit. Eadcliffe, who justly 
ranks as one of the first authorities in nervous diseases, gives the prefer- 
ence to the iodide of iron, believing that iodine, as well as iron, exerts a 
curative influence. I have of late inclined to the use of the ammonio- 
citrate, as it is easy of administration in simple syrup, and is well tolerated. 

Arsenic, highly extolled by Romberg and others, is a remedy of un- 
doubted value. It is conveniently given in Fowler's solution. It should 
be administered in doses of three to five drops three times daily, after the 
meals, as in the treatment of cutaneous or other affections. Radcliffe has 



460 CHOREA. 

administered by subcutaneous injection Fowler's solution, diluted with an 
equal quantity of water, in a few cases of obstinate local chorea, with a 
satisfactory result. An adult with choreic movements in one side of the 
neck of nine years' duration was nearly cured by fourteen injections em- 
ployed at intervals of a few days, the quantity employed being increased 
gradually from three to fourteen minims of the solution. Strychnia is 
another remedy which has been found useful. Trousseau, who prescribed 
it in most cases, and highly extolled it, employed the following formula : — 

!£.. Strychnise sulpliat., gr. j ; 
Syr. simplic, Jijss. Misce. 

A child of the ordinary age, say ten years, takes at first a teaspoonful 
twice or three times daily, at uniform intervals, and the dose is gradually 
and cautiously increased until it begins to produce physiological effects. 
Strychnia, when employed to the extent of causing some rigidity, is more 
efficient as a remedy, but smaller doses have been found useful. 

Professor Hammond (Diseases of the Nervous System, page 617) says: 
" My main reliance is on strychnia, which, I think, should be given in 
gradually increasing doses, somewhat after the manner recommended by 
Trousseau. . . . This plan of treatment certainly shortens the duration of 
the disease very materially, and causes great improvement in the general 
health of the patient. Sometimes the effect is so well marked, and is so 
immediate, that it is not necessary to increase the doses to the extent of 
causing muscular cramps, but generally the full therapeutical effect of the 
drug is not obtained till the calf of the leg or the nucha has slight tonic 
spasm. I have never seen the slightest ill-consequence follow this mode 
of treatment, and the doses are increased so gradually that, with careful 
watching, danger need not be apprehended." Dr. Hammond has treated 
thirty-two children with this agent without a single failure. 

But as chorea terminates favorably with smaller and safe doses, even if 
the time required is longer, it does not seem proper to recommend its em- 
ployment to the extent of producing physiological effects for general prac- 
tice. Bouchut, speaking upon this point, says : " But, with these precau- 
tions, strychnia is extremely dangerous, for I have seen, at the Hopital des 
Enfants Malades, a young girl of thirteen years die in tetanus," produced 
by an increased dose of this drug (article on Chorea). Dr. West, in his 
Lumleian Lectures, also says : " I have seen one instance in which its em- 
ployment, while it failed to benefit a somewhat severe case of chorea, was 
followed by two attacks of violent tetanic convulsions, which nearly proved 
fatal ;" and he adds, " The twitching of the limbs of itself prevents our 
becoming aware of the dose being excessive, and a child's inability to de- 
scribe its sensations deprives us of another." For such reasons, Dr. West 
does not favor the employment of this agent. Still, any agent may be 
given in an overdose, and it is not difficult to prescribe strychnia in a dose 



TREATMENT. 461 

which will be efficient and yet safe for children at the age at which chorea 
ordinarily occurs. I have employed bromide of potassium in a few cases, 
but with so little benefit that I am not inclined to continue its use for this 
disease. Others have not been more successful. However efficacious the 
bromide may be in epilepsy, it does not appear to be a remedy for chorea. 

Cimicifuga, first employed by Jesse Young of this country, is highly 
esteemed by Philadelphia physicians in the treatment of chorea. I have 
employed the fluid extract in doses of half a drachm, increased to one 
drachm, for a child from six to ten years of age, and though it benefits 
some cases, it has no appreciable effect either in moderating the move- 
ments or abridging the duration of others. 

Ether, asafcetida, valerian, musk, the oxide and sulphate of zinc, tur- 
pentine, tartar emetic, opium, and numerous other remedies, have been 
recommended, and some of them have seemed useful in certain cases. In 
this city sulphate of zinc has been frequently employed as a remedy for 
chorea, and in gradually increasing doses till more than twenty grains 
were administered three times daily, but it has not appeared, so far as I 
have been able to ascertain, to exert any marked influence either on the 
severity or duration of the choreic movements. Justice, however, requires 
us to state that Dr. AYest, who has written recently on the nervous dis- 
orders of children, thinks that it has been beneficial in certain cases in 
which he has employed it, and regards it on the whole as the best remedy. 

Radcliffe, who has had ample experience in the treatment of nervous 
affections, writes : "In an ordinary case of chorea the plan of treatment 
which I have now adopted as a rule for some time is to give cod-liver oil, 
in conjunction with hypophosphite of soda, making the draught containing 
the latter salt the vehicle for the administration of the cod-liver oil." 
Sometimes camphor or the sesquicarbonate of ammonia is added. Of more 
than thirty cases treated in this way, the average duration was under three 
weeks. Radcliffe began to prescribe these remedies on theoretical grounds, 
believing that phosphorus and cod-liver oil were required to restore 
" nerve tone," and the result of this treatment has certainly been such as 
to commend it to the profession. To children he gives from five to eight 
grains of the hypophosphite of soda three times daily. 

Although strychnia and cod-liver oil are recommended by high authori- 
ties, the arsenical treatment, with iron as an adjuvant, has seemed to me 
the most useful. It is employed in the large class in the Bureau for the 
Out-door Poor, in preference to the strychnia and cod-liver oil, and we 
confidently expect that when the full dose is employed, the patient will 
begin to improve in a few days. Children tolerate arsenic better than 
adults, as I have stated elsewhere, and a child of five years can take five 
or six drops of Fowler's solution, after the meals, if smaller doses do not 
have the desired effect. 

In those severe cases in which the choreic movements prevent the 



462 INFANTILE PARALYSIS, 

proper amount of sleep, a moderate dose of hydrate of chloral may occa- 
sionally be advantageously administered. 

Electricity has been many times employed in the treatment of chorea, 
and though some, chiefly electricians, believe that it has a curative effect, 
others, and the majority, fail to see any material benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc., have 
been employed ; but the local treatment which has so far been most suc- 
cessful, and which promises to supersede all others, consists in the applica- 
tion of ether spray over the spine. About two ounces of ether are 
employed at each sitting, the spray being applied from an atomizer up and 
down the whole length of the spine if the chorea is general. The opera- 
tion, which occupies from ten to fifteen minutes, should be repeated daily 
or every second day. A considerable number of cases have been reported, 
in which the spray has apparently had a good effect in controlling the 
disease. 



CHAPTER XV. 

INFANTILE PARALYSIS. 

Paralysis in young children, especially infants, is in most instances 
due to causes which seldom produce it in adults. The principal cause of 
it in the adult, namely, cerebral apoplexy, is indeed rare in children. 
Paralysis in children has the following recognized causes : 1st. A change 
in the blood, not fully understood, induced by certain grave diseases, as 
diphtheria, typhoid fever, measles, scarlet fever, etc. 2d. Reflex influence. 
The function of some part of the system is in some way disturbed, and 
paralysis occurs in certain muscles, maybe at a distance from the cause, 
and it disappears when that cause is removed, unless it has continued too 
long. The only rational explanation is found in the fact of a continuous 
connection between the local cause and the paralyzed muscles through 
the afferent and efferent nerves, and the nervous centres. 3d. Compression 
or injury of a nerve-trunk. These cases are rare. Pressing of the portio 
dura by the blades of forceps during birth, described in the next chapter, 
is an example. 4th. An anatomical alteration in the muscular fibres, the 
nerves and nervous centres remaining unaffected. This has been desig- 
nated myogenic paralysis. This form of paralysis is probably often of a 
rheumatic nature. Paralysis of the face or other portions of the surface, 
which sometimes occurs in children and adults from prolonged exposure to 
cold winds, is of this nature. 5th. Some anatomical change in the ner- 
vous centres, as congestion, hemorrhage, inflammation, emboli, compres- 
sion and laceration of brain, whether by tumors, inflammatory products, 



case. 463 

or other causes, etc. If there is hemiplegia the presumption is that the 
disease causing it is cerebral ; if paraplegia, that it is spinal. The follow- 
ing is an interesting example of hemiplegia. The case was related by 
me, and the specimen presented to the New York Pathological Society. 

Maggie, aged 2 years 8 months, was admitted into the Catholic Found- 
ling Asylum about the 1st of September, 1874. She seemed to be in good 
health and was plump and well developed, and her mother stated that she 
had had no serious sickness. After her admission she continued well, 
having the usual appetite, amusing herself through the day, and presenting 
no symptoms to attract attention till December 6th. On the evening of 
December 5th she ate her supper as usual, and was placed in her crib, 
apparently in perfect health. At 3 A. M., the sister who was in charge 
of the ward, found her in severe general eclampsia. Immediately, in addi- 
tion to the usual local treatment, she administered five grains of bromide 
of potassium, and this was repeated at intervals till six or seven doses 
were administered. Nevertheless, the spasmodic movements continued, 
with more or less violence, till 1^ P. M., and in the muscles of the neck 
somewhat longer. 

On my arrival at the asylum, at about 6 P. M., I found her lying quietly, 
rather stupid, but easily aroused. Her vision was evidently good, and 
she was conscious ; the pupils responded to light, and the direction of the 
eyes was normal ; pulse 104, no cough, and respiration natural ; tempera- 
ture, as ascertained by the thermometer in the axilla, also normal. There 
was no apparent paralysis of the muscles of the face, but the right arm 
and leg were paralyzed, though the paralysis was not complete. The 
great toe flexed on tickling the sole of the foot, but the foot itself had 
little or no motion, and on my attempting to flex the leg, which was ex- 
tended, some rigidity of the muscles was observed. At times the patient 
produced slight movement of the thigh upon the trunk. The muscles of 
the right upper extremity were more flaccid than those of the leg, and 
below the elbow motion seemed to be totally lost, while a little movement 
remained of the arm on the trunk. I think that during the two or three 
days succeeding the convulsions sensation in the right limbs was not en- 
tirely lost, though greatly enfeebled. Subsequently paralysis in the right 
limbs, both of the nerves of sensation and motion, was nearly or quite 
total, and continued so till death. Nevertheless, tickling the sole of the 
foot caused some movement of the great toe. On the left side sensation 
and motion were perfect. 

The record of December 9th runs : Has vomiting to-day for the first 
time ; apparently sees well, and appearance of the eyes normal ; has no 
retraction of head, or rigidity of muscles of neck, or along the spine ; 
pulse 96, temperature in the axilla normal; lies quiet and with eyes shut; 
is stupid, but not particularly fretful, when aroused ; the bowels move 
regularly. 

December 11th, continues to vomit at intervals ; pulse 68. Dec. 16th, 
pulse 80, temperature 100 ; vomited once yesterday, none to-day ; lies in a 
constant doze ; takes bromide of potassium gr. iv three times daily. Dec- 
18th, moans at times, as if in pain ; pulse 180, temperature 100; takes the 
bromide gr. iv every four hours. 

Dec. 19th, pulse 180, temperature 103 ; there is convergent strabismus, 
and the eyes have a wild, almost insane, look, but she sees, grasping hur- 
riedly a percussion hammer presented towards her ; paralysis of nerves of 
motion and sensation in the right extremities nearly complete ; slight move- 



464 INFANTILE PARALYSIS. 

ment is still produced in the great toe by titillation ; the vomiting has 
ceased ; tongue covered with a thick fur ; movements of the bowels pretty 
regular ; has a slight cough, such as is common in cerebral disease. 

Dec. 22d, lies quietly on her side in perpetual slumber, with eyes con- 
stantly shut ; pulse 118, temperature 101^° ; the bowels still move nearly 
normally ; the pupils, exposed to the light, are seen to oscillate, but are 
constantly more dilated than in health ; the urine passes freely ; circum- 
scribed flushing of the features at intervals ; a rash like lichen over 
abdomen and chest, possibly due to the large quantity of bromide of po- 
tassium administered. 24th, pulse intermittent ; pupils dilated. 

Dec. 25th, died in profound stupor to-day, having lived nineteen days 
from the commencement of the malady. 

Autopsy. — About thirty hours after death ; weather cool. On removing 
the calvarium and dura mater, which presented no unusual appearance, 
the vessels of the pia mater were found rather more injected than usual, 
but not more so than we sometimes observe in those who die of diseases 
which do not involve the brain. The cerebro-spinal fluid was scanty, and 
the surface of the brain rather dry. The vertex of the left hemisphere 
was unusually prominent, rising perhaps half an inch higher than that on 
the opposite side. At the highest point, which was about one and a half 
inches from the median line, was a circular yellowish spot upon the surface 
of the brain about one and a half inches in diameter. Pressure upon 
this spot, made lightly, so as not to produce rupture, communicated the 
sensation of a large cavity underneath filled with liquid, and approaching 
to within two or three lines of the surface. There was no adhesion or 
exudation over this spot ; and the surface of the brain appeared entirely 
normal, except a little cloudiness of the pia mater over a space which 
could be covered by a five-cent piece, a little posterior to the optic com- 
missure. The incised surface of the brain, at a distance from the abscess, 
showed no increase of vascularity. The right hemisphere appeared in 
every way normal, except that its lateral ventricle was filled with pus,. but 
not distended. 

On the left side, occupying the centre of the hemisphere, was an abscess 
as large as the fist of a child of two years, extending from within two or 
three lines of the vertex, where its site corresponded with the yellow spot 
on the surface of the brain, to the roof of the lateral ventricle. Through 
this roof the abscess had burst, filling and distending the ventricle with 
pus, and thence making its way into the lateral ventricle of the opposite 
hemisphere. The whole amount of pus contained in the abscess and the 
two ventricles was, perhaps, two ounces. The walls of the left lateral 
ventricle were much softened, the upper part of the corpus striatum and 
thalamus opticus being nearly diffluent ; the walls of the right lateral 
ventricle were slightly softened, but to less depth. The parietes of the 
abscess, which extended from the roof of the ventricle to the vertex, as 
already stated, were indurated to the depth of one and a half lines in 
consequence of proliferation of the connective tissue, except at the base 
of the abscess, which corresponded with the roof of the ventricle, where 
softening had occurred. The spinal cord, so far as it could be examined 
from the cranial cavity, had the usual vascularity, and seemed nearly or 
quite normal. 

The cause of the encephalitis from which the abscess resulted was ob- 
scure. This inflammation, so far as can be ascertained, was idiopathic, 
which is known to be a rare disease. There was no history of otitis, which 
is one of the most frequent causes of cerebral abscess, nor of heart disease, 



SYMPTOMS. 465 

so as to produce embolism. It seems probable, since there was no fever 
till about the fourth day after the convulsions, that an abscess had pri- 
marily occurred in the hemisphere between the roof of the ventricle and 
the vertex, possibly weeks previously. The bursting of this into the lateral 
ventricle, and the constitutional disturbance, inflammation, and softening 
to which this would inevitably give rise afford sufficient explanation of the 
history of the case after the commencement of the convulsions. 

Paralysis occurring as a symptom, or sequel of some obvious local or 
general disease, as diphtheria, lesion of the nervous centres, etc., and 
which may occur at any age, need not detain us. It is described in con- 
nection with the primary diseases on which it depends. But there is a 
form of paralysis which in the present state of our knowledge we must 
consider an idiopathic malady, and which is peculiar to the first years of 
life, or is so rare at other periods that it is proper to regard it as strictly 
a malady of infancy and early childhood. It occurs between the ages of 
six months and three years. The following description relates to it : — 

Symptoms The previous health of the patient is usually good. The 

paralysis does not always commence in the same manner. In a few 
instances it begins suddenly in the daytime when the child is apparently 
in perfect health. In some it begins abruptly, after sound sleep. The 
child goes to bed well, sleeps through the night, and awakens in the morn- 
ing paralyzed. I have known it to occur in one instance after sleep in the 
middle of the day. In these cases there has sometimes been an exposure, 
before the sleep, to wind or rain, or from sitting upon a cold stone. In 
other and the majority of cases the paralysis is preceded by a very decided 
febrile movement, which comes on suddenly, without appreciable cause, 
and after a few days the power of motion is found to be lost in one or 
more of the limbs. There is no symptom during the febrile movement 
to indicate any affection of the brain : consciousness is retained, and there 
is no more headache or apparent liability to convulsions than occurs 
in other pathological states accompanied by an equal amount of fever. 
Several other modes of commencement have been described by writers, 
but it is not improbable that they have embraced other forms of paralysis 
in their statistics, as for example those cases which are hemiplegic, or 
which occur in the course of a lingering disease, or a hemorrhagic disease, 
or with cerebral symptoms, as vomiting. Such cases should not in my 
opinion be included in the statistics of infantile paralysis, since their 
nature is uncertain, nor indeed should any cases in which there is doubt 
as to their genuineness. In whatever way the paralysis begins, it is at its 
maximum in the commencement. Occurring as by a stroke, the full ex- 
tent of the paralytic state is exhibited at once, and so far as there is any 
subsequent change, it is an improvement, as regards the number of muscles 
affected, and the degree of the paralysis. Most frequently the muscles of 
one or both lower extremities are affected. Occasionally one of the upper 
30 



466 INFANTILE PARALYSIS. 

extremities is also paralyzed in addition to the lower, but paralysis of an 
upper extremity is less in degree, and disappears sooner, than that of the 
lower. The bladder and lower bowels remain unaffected, since only the 
muscles of volition are involved. Sensation is unimpaired in the affected 
limbs, and in the commencement there is even in some cases a state of 
hyperesthesia (West). The febrile movement, which precedes and ac- 
companies the paralysis in certain cases, gradually abates, and in a few 
days nothing abnormal remains except the loss of power in the affected 
muscles. These muscles are in a flaccid and relaxed state, so that the 
limb falls by its weight when unsupported, and they are usually free from 
pain. The number of muscles paralyzed varies greatly in different cases. 
Only one muscle or a single group of muscles may be affected, or, on the 
other hand, both the extensor and flexor muscles of two or more limbs. 
In the opinion of Mr. Adams, the following table exhibits the groups of 
muscles and single muscles most frequently involved, and in the order 
stated : — 

Groups. 

1. Extensors of toes, and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

The following is an example of infantile paralysis, as it not infrequently 
occurs when the result is favorable : A. K., German, female, aged 3 
years 4 months, fleshy ; had been in the habit of sitting on the ground 
near the house and on the door-sill. On July 2, 1871, she had a sound 
sleep in the afternoon, having been entirely well previously, and awoke 
trembling and with a high fever at 3 J- P. M. At 8 P.M., the febrile excite- 
ment continuing, general clonic convulsions occurred, lasting about ten 
minutes. At this time I was called to see her, and found her face flushed, 
surface hot, and pulse about one hundred and thirty. Consciousness re- 
turned after the convulsion. Her intelligence was good, tongue moist and 
slightly furred, bowels rather constipated, and the urine freely passed. 
The febrile excitement continued two days, when it gradually and entirely 
abated, but before it ceased paralysis of the left lower extremity was ob- 
served. No weight at first could be sustained upon this limb, and it hung 
powerless when we endeavored to make her walk. The attempt caused her 
to cry, as if in pain, and pressing upon the thigh, or moving it, had the 
same effect. The thigh of this limb did appear slightly swollen on inspec- 



PROGNOSIS — PROGRESS — ETIOLOGY. 467 

tion, but measurement did not indicate any notable enlargement. The 
difference in circumference was certainly not more than one-eighth to one- 
fourth of an inch. There was no appreciable increase of heat in the thigh 
over the general temperature of the body. Sensibility remained in every 
part of the limb, and the loss of power was not complete, for on the first 
day, as soon as the paralysis was observed, slight and imperfect movements 
could be produced by pinching the limb. In three weeks the use of the 
limb was fully restored, by mildly stimulating liniments, and simple medi- 
cines to regulate the bowels. The tenderness which was observed in this 
case, is only occasionally present. It has been attributed to hyperesthesia, 
but those who hold to the peripheral origin of the paralysis, would probably 
attribute it to the anatomical change occurring in the terminal nerve- 
fibres. 

Prognosis — Progress — The paralysis in nearly all cases soon begins 
to abate. The power of motion returns little by little, and whatever im- 
provement occurs is permanent. There is no retrogression in the convales- 
cence. The sooner improvement commences, the more favorable is the 
prognosis. In the most favorable cases there is complete restoration in 
from three to four weeks. In other patients, while certain of the muscles 
regain the power of motion, other muscles, oftener those of the lower ex- 
tremity than upper, do not reeover their function, and, unless proper 
remedial measures are employed, and even with them in certain instances, 
atrophy soon commences. The temperature of the paralyzed limb falls 
three, five, or even eight degrees, and the amount of blood which circulates 
in it is diminished so that the pulse of the limb is feebler and its vessels 
smaller than in health. With the atrophy the contractility of the muscular 
fibres by the electric current diminishes, and in unfavorable cases after a 
time powerful induced and even primary currents have no appreciable effect. 
The nutrition of a paralyzed limb is always imperfect, and if the paralysis 
occur in a child, its growth is retarded. Therefore in cases of protracted 
or permanent infantile paralysis of one limb a disproportion occurs both in 
diameter and length between it and that on the opposite side. If the 
paralysis continue, the ligaments of the paralyzed limb become relaxed and 
lengthened. West mentions a case of paralysis of the deltoid in which the 
humero-scapular ligaments were so extended that the humerus dropped 
from the glenoid cavity, so as to increase the length of the limb three-fourths 
of an inch. In the paralysis of certain muscles of the lower extremity, and 
continuance of the contractile power in others, we have the conditions which 
give rise to club-feet, and accordingly this deformity is the common result 
of the paralysis when it is not cured. 

Etiology As infantile paralysis is not a fatal malady, opportunity 

for a post-mortem examination in a recent case seldom occurs. Hence 
the difficulty in determining the exact anatomical change in the nervous 
system which produces the paralysis. There are now in medical literature 



468 INFANTILE PARALYSIS. 

records of a considerable number of cases in which autopsies have been 
made, but death occurred so long after the commencement of the para- 
lysis, usually months or years, that it is difficult to determine whether 
lesions which have been observed were a cause or consequence. In a 
majority of these autopsies a spinal lesion of some sort was detected, but 
none could be discovered in a few instances, the most important of which 
were the following : — 

Mr. Adams, in his treatise on club-foot, relates a case in which the spinal 
cord, carefully examined, probably only with the naked eye, seemed 
normal. Robin examined the spinal cord microscopically in one case, but 
discovered nothing abnormal, and Elischer made two autopsies in cases of 
this paralysis which had succumbed in variola, but with a negative result 
as regards any lesion in the nervous system (Jahrbuch fur Kinderk., 1873). 
The examinations by Robin and Elischer, since they were microscopic, 
have been justly regarded as important, and they have been related by 
certain writers in order to sustain the theory that infantile paralysis is 
peripheral, and not centric. But may there not have been a spinal lesion 
which caused the paralysis, and abated, leaving no trace, although its 
effects as regards the muscles continued ? 

Very little was effected, prior to 1863, in determining the cause or 
causes of infantile paralysis by post-mortem examinations, because the 
microscope was so little used, and because in most of the cases reported 
the clinical history or microscopic lesions were such as to show or to render 
it highly probable that the paralysis was not such as is designated and 
understood by the term infantile. Thus Beraud reported a case in which 
tubercles were found in the spinal cord. Hutin, a case in which there 
was atrophy of the lower part of the spinal cord, but the paralysis com- 
menced at the age of seven years. Hammond, a case in which a clot was 
found in the spinal cord ; and Jaccoud, one of spinal arachnitis, with thick- 
ening of the meninges. Since 1863, seventeen autopsies have been re- 
corded in which the spinal cord was carefully examined, and upon these 
we must chiefly rely for our data by which to determine what are the ana- 
tomical changes in the nervous system which probably cause this paralysis. 
The reader will find these cases tabulated in a lecture by E. C. Seguin, 
M.D., published in the N. Y. Med. Record, January 15th, 1874, and the 
most important of them narrated in a paper on infantile paralysis, showing 
great research, published by Dr. Mary Putnam Jacobi, in the N. T. Obst. 
Journ. for May, 1874. It is true that all but three of these post-mortem 
examinations were made many years after the occurrence of the paralysis ; 
but in the three cases which were reported by Roger and Damaschino, 
only two, six, and thirteen months had elapsed. The following were the 
chief lesions observed in these cases as regards the spinal cord : — 



ETIOLOGY. 469 

Cases. 

1. Atrophy of motor-cells in anterior cornua . . . .10 

2. Nerve-cells, normal 2 

3. Atrophy (variously recorded) of anterior columns, or cornua, 

or part of cord, or roots of anterior nerves ... 8 

4. Sclerosis .......... 9 

5. Myelitis, recorded as diffused, central, or slight ... 7 

6. Central softening (the three most recent cases) ... 3 

7. Small clot in cord (Hammond's case) ..... 1 

8. Sciatic neuritis ......... 1 

It is seen that the most common lesions in these cases were those of 
inflammation of the spinal cord, or snch as are known to result from this 
inflammation, to wit, atrophy of the nervous substances and sclerosis. 

With the data furnished by these post-mortem examinations and the 
clinical histories of cases, we are the better prepared to consider the theo- 
ries regarding the etiology of this malady. The views of MM. Roger and 
Damaschino are entitled to great consideration, since the autopsies which 
they made were in cases of shorter duration, and therefore nearer the date 
of the commencement of the paralysis than those which have been reported 
by other observers. Roger and Damaschino published a series of papers 
on this malady in the Gaz. Med. de Paris in 1871, which they conclude 
with the following propositions : "1. The alteration peculiar to infantile 
paralysis is a lesion of the spinal marrow, which causes the atrophy of 
muscles and nerves. 2. The seat of this lesion is the anterior part of the 
gray substance of the medulla, where softened portions of spinal substance 
are seen. 3. This softening is of an inflammatory nature — in fact, a 
simple myelitis. 4. Infantile paralysis should, therefore, be called spinal 
paralysis of children, and be classed among the affections of the spinal 
marrow, as depending on myelitis." 

To determine the exact character and limitations of the cause of infan- 
tile paralysis is difficult; but the views of Roger and Damaschino, as ex- 
pressed in the above propositions, seem to harmonize more closely with, 
and to afford a more satisfactory explanation of, the symptoms, history, 
and lesions, thus far observed in ordinary or typical cases, than does any 
other theory. Suddenly occurring, active congestion of the anterior cor- 
nua, many neuropathists regard as the cause of infantile paralysis ; but 
there is that close affinity between active congestion and inflammation 
that they may be regarded as having the same pathological effect in this 
instance, and therefore the two theories of a spinal congestion and spinal 
inflammation may be considered as one. It is not improbable that in 
some of the cases which more speedily recover there is simple congestion ; 
while in the more obstinate cases, and those with inflammatory symptoms, 
the congestion has passed into an inflammation, or inflammation was 
present from the first. According to this theory, the atrophy so generally 
observed in the twelve cases in which autopsies were made, must be con- 



470 INFANTILE PAKALYSIS. 

sidered a degenerative change resulting from the inflammation or from the 
paralysis. That so accurate an observer and so excellent a microscopist 
as Robin could detect nothing abnormal in the case which he examined, 
was probably due to the fact that the inflammation or congestion abated 
without producing any degenerative changes in the nervous substance. 

Professor Charcot considers atrophy of the motor cells as the cause of 
the paralysis, but it is much more in consonance with the facts to consider 
the cellular atrophy a result than a cause. For how could atrophy, which 
always occurs gradually, and by progressive increase, be the cause of a 
disease which begins abruptly, and is most intense in the very commence- 
ment ? Besides, atrophy does not occur without some antecedent disease 
to cause it. 

It would be a waste of time to consider in full the various theories re- 
garding the cause of infantile paralysis. No one at the present time of 
those who are competent to express an opinion, believes it to be a reflex 
paralysis, and the expression dental paralysis once applied to it is no longer 
heard. There is one theory, however, which should receive more than a 
passing notice, and which was earnestly and ably advocated by Barwell, 
of London, in lectures published by him in 1872, in the London Lancet, 
to wit: " That this paralysis is purely peripheral; a malady affecting the 
ultimate fibrillas of distribution of the nerves among the muscular ele- 
ments. . . . Its essence," says he, "lies probably in some subtile derange- 
ment in relationship between the ultimate muscular and terminal nerve- 
fibres, perhaps from some inflammatory, perhaps from some chemical or 
nutrient change." This theory has much to commend it. Those who ad- 
vocate it believe that the atrophy of the nerves which supply the para- 
lyzed limbs and of the motor nerve-cells which connect with the roots of 
these nerves in the anterior cornua occurs in consequence of the paralysis, 
just as atrophy of the optic nerve can be traced even into the brain when 
the eye is destroyed. Nor does it dispose of this theory to state, as has 
been stated, that in order that paralysis occur in this manner, it is neces- 
sary that there should be the action of a poison, analogous to the woorari, 
for Ave observe something similar to this supposed peripheral cause in facial 
paralysis from exposure to cold, in which there can be no poisonous in- 
fluence. This theory therefore rises up most strongly in conflict with that 
which attributes the paralysis to a congestion or inflammation of the an- 
terior cornua, and it is necessary to decide between them, or to admit that 
the paralysis may sometimes have one and sometimes the other cause. 
But the fact that. there is in many cases of infantile paralysis a decided 
febrile movement, and much constitutional disturbance, when there is no 
evidence of any morbid action going forward in the affected limbs suffi- 
cient to cause these symptoms, and the fact that only one set of nerves is 
affected, namely, the motor, which have a distinct origin in the spine from 
the sensitive nerves, but are intimately associated with them in their dis- 



ANATOMICAL CHARACTERS — PROGNOSIS. 471 

tribution, comport best with the theory of a central lesion. Therefore, the 
theory of spinal congestion or inflammation appears the best established. 
Nevertheless, all past experience shows that medical theorizers are apt to 
be too exclusive, and that in many diseases there is not a simple uniform 
cause, but that the cause may vary, especially when, as in the present 
instance, the symptoms also vary; possibly, therefore, we may yet find 
that there are cases, especially those in which there is little constitutional 
disturbance and a known exposure to cold, in which the cause is peripheral 
instead of centric. The brain and cerebral meninges may be excluded as 
sustaining any causative relation to the paralysis. There is no symptom 
which indicates that they are involved. The mind remains clear, and con- 
vulsions are no more frequent than in any other disease which is attended 
by an equal degree of febrile reaction. 

Anatomical Characters. — All muscular fibres Avhich are in a state 
of disuse, begin in a few weeks to atrophy, and undergo fatty degenera- 
tion. The transverse striae in the primitive muscular fasciculus gradually 
disappear and are replaced by granules of fat, and later still by small oil- 
globules. If we examine with the microscope the fibres from a muscle 
which has been a considerable time paralyzed, but which has still some 
electric contractility, we will find in places the stria? remaining, but numer- 
ous opaque granules of a fatty nature within the sarcolemma wherever the 
stria? are absent, and in other places, where the degeneration is most 
advanced, oil-globules occur, always small. If the paralysis is more pro- 
found, the stria? have all disappeared. At a later stage, usually after some 
years in cases of complete and incurable paralysis, the fatty matter may 
be to a considerable extent absorbed, and the fibrous network of the muscle 
which remains presents a tendinous appearance. There is a great differ- 
ence, however, in different cases, as regards the rapidity with which these 
changes occur. Hammond states that he found the stria? remaining in 
two cases after the lapse of more than four years of decided paralysis. 
The nerves of the paralyzed part also undergo atrophy. 

Diagnosis. — This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the 
mother or nurse first observes the paralysis, and calls the attention of the 
physician to it. A knowledge and recollection of the facts in relation to 
infantile paralysis should lead the physician to examine the state of the 
limbs in all cases of marked febrile excitement in young children, occur- 
ring without apparent cause. 

Prognosis It may be confidently predicted, if the child is seen early, 

and correctly treated, that the paralysis will diminish, if it cannot be en- 
tirely cured. If the paralysis have continued a considerable time, and there 
is no electric contractility of the muscles, there is poor prospect of any 
improvement. The induced current will fail, sometimes, to cause muscular 
contraction, when the direct current may produce it ; but if there is no 



472 INFANTILE PARALYSIS. 

response to the direct current, there is no therapeutic agent which can 
restore the use of the limb. 

In cases seen soon after the paralysis commences, and before the stage 
of atrophy, the prognosis is most favorable, when there is still slight vol- 
untary motion, and improvement commences early. In most instances, 
even when the paralysis has been mild, and of comparatively short dura- 
tion, the limb, although its motion is fully restored, is for a long time 
weaker than the limb on the opposite side. 

Treatment — A physician called at the commencement of the paraly- 
sis should endeavor to remove every cause which might increase the 
irritability of the nervous system. It is proper to scarify the gums, if 
much swollen and tender from dentition, the bowels should be kept regular, 
worms, if present, expelled by appropriate medicines, and the diet be 
plain and unirritating. As the cause of the paralysis is, in the commence- 
ment, still operative, measures are appropriate which are calculated to 
remove it. 

Local treatment is very important at all periods of the paralysis. In 
the first days a tepid hip-bath employed daily, with brisk friction of the 
surface, has a salutary effect. Stimulating embrocations along the spine, 
and upon the paralyzed limb, are appropriate also at an early date. Pos- 
sibly, if there is a strong probability of spinal congestion, cold applied 
along the spine, by ether spray or otherwise, might be useful, but I am 
not aware that it has been employed in this disease. If the paralysis 
appear to have a central origin, ergot, the bromide and iodide of potassium, 
which may be administered variously combined, or singly, are the appro- 
priate remedies for the first twelve or fourteen days. Administered every 
three or four hours in proper dose, they are the most effectual of all inter- 
nal remedies for diminishing spinal congestion, and preventing effusion, 
and permanent structural change in the cord. 

If the paralysis continue, or if it do not progressively diminish, we should 
not delay more than two weeks from the commencement of the disease be- 
fore employing appropriate measures to restore the use of the limbs, and 
prevent atrophy of the muscles. The expectant plan of treatment which 
is proper in many diseases of children is unsuited to this. Muscular 
atrophy may commence in three weeks, and the further it has advanced, 
the more difficult and tedious will be the cure. Therefore, by the close 
of the second week if the paralysis continue, or is not rapidly disappearing, 
iron as a tonic with strychnia should be prescribed. There is probably 
no better formula for the exhibition of these agents than the following 
from Professor Hammond : — 

]$. Strych. sulphat., gr. j ; 
Ferri pyrophosphate 3 SS ! 
Acidi phosphorici dilut., §ss ; 
Syr. zingib., §iijss. Misce. 



FACIAL PARALYSIS. 473 

One-third of a teaspoonful, or one-ninetieth of a grain of strychnia, is 
sufficient for a child of two years, administered three times daily. Hillier, 
Barwell, and others have employed subcutaneous injections of strychnia, 
with, it is stated, a good result. While in the first and second weeks the 
child has been allowed to remain quiet, he should now be encouraged to 
use his limbs. Frequent muscular contraction must, if possible, be pro- 
duced, and the voluntary movements, when not totally lost, aid greatly in 
promoting the nutrition of the muscles and restoring their function. 
Immersing the limb for half an hour in water at a temperature of 110 or 
115 degrees, rubbing the limb with a coarse towel, and kneading the 
muscles, aid also in restoring nutrition and tone to them. 

But, fortunately, we have an invaluable agent in the subtle electrical 
fluid, which can be made to penetrate the muscles and cause their contrac- 
tion when every other measure has failed. The induced current should be 
employed upon the limb every day, or second day, if it cause the muscles 
to act, but if the loss of power is of long standing, or complete, so that the 
induced current is not sufficiently powerful, the direct current should be 
used instead. It is not regarded as important which way the current 
passes, provided the muscles contract. 

In a large proportion of cases a cure cannot be effected until the lapse 
of several months, so that the patience of the physician and friends may 
be put to the test; but if muscular atrophy can be prevented, and the 
limb kept at near the normal temperature, this mode of treatment will 
ordinarily in the end be successful. The primary affection which caused 
the paralysis will, with some exceptions, abate of itself, so that the state 
of the muscles and their nervous supply demand the whole attention. Ob- 
servations show that by treatment perseveringly employed, fatty degenera- 
tion of the muscular fibres can be not only arrested, but the fat which has 
already been deposited within the sarcolemma may be absorbed, and the 
muscular strice restored. In those cases in which it has been necessary to 
employ the direct current, the induced should be employed, whenever by 
the improvement of the case it is found sufficiently powerful. 



CHAPTER XVI 

FACIAL PARALYSIS. 



Causes — Facial paralysis, in the newborn, commonly occurs from 
pressure of the blade of the forceps upon the portio dura, at a point ex- 
ternal to the stylo-mastoid foramen. It may also occur in children of 
any age, as it is known to be in the adult, from exposure of the face to a 



474 FACIAL PAEALYSIS. 

cold wind. The pressure of a tumor upon some part of the portio dura, 
or even of the fist of the child placed under the face during sleep, may 
cause it. It may also result from disease of the temporal bone, producing 
pressure on the nerve, as caries, periostitis, suppuration, or hemorrhage 
into the aquasductus Fallopii, and also from intracranial disease affecting 
the pons Varolii or the medulla oblongata. 

Symptoms — The portio dura, which is a nerve of motion, supplies the 
muscles of the face, and therefore its loss of function is at once manifest in 
distortion of the features. The eye of the affected side remains open in 
consequence of paralysis of the orbicularis palpebrarum, the upper lid 
being raised by the levator muscle, which is not paralyzed, as its nerve is 
derived from the third pair. From the inability to wink, the eye becomes 
irritated by dust and constant exposure, and, in children old enough to 
have an abundant lachrymal secretion, the tears are apt to flow over the 
cheek. On account of the paralyzed and relaxed state of the facial muscles 
the mouth is drawn towards the healthy side, while the affected side pre- 
sents a swollen appearance. Movement of the eyebrow and of the anterior 
portion of the scalp on the paralyzed side is also impossible, since the 
occipito-frontalis and corrugator supercilii are supplied by the portio dura. 
If the cause of the disease is located above the origin of the chorda tym- 
pani, the flow of saliva, and consequently the taste, on the affected side 
are impaired. If the injury is posterior to the gangliform enlargement, 
those symptoms are superadded which are due to paralysis of the petrosal 
nerves. 

Prognosis This depends on the cause. If the cause is peripheral, as 

from the pressure of the forceps or from cold, the prognosis is favorable. 
In cases of deep-seated lesion, unless syphilitic, the prognosis is usually 
unfavorable. A syphilitic lesion can often be removed by appropriate 
remedies and the paralysis cured. 

Treatment In the paralysis of the new-born, from pressure of the 

forceps, all that is required is occasional rubbing or gentle kneading over 
the affected muscles. In those who are older, the nature of the cause, so 
far as ascertained, must determine the treatment. If there are glandular 
swellings, and discharge from the ear from scrofula, cod-liver oil and the 
syrup of the iodide of iron are required internally, with appropriate ex- 
ternal treatment of the glands and ear. If syphilis is the cause, mercurials, 
and the iodide of potassium should be employed. If the patient do not 
soon begin to improve, the treatment recommended for infantile paralysis, 
modified somewhat on account of the difference in location, is appropriate. 
Iron and strychnia may be administered internally; friction, kneading, 
hot applications, and the electric current employed. The current should 
have only moderate intensity, for a high degree of it might injure the 
vision. It should be applied every second day, with one pole over the 
mastoid foramen, and the other moved slowly over the muscles. 



PARALYSIS WITH PSEUDO-HYPERTROPHY. 475 

Paralysis with Pseudo-Hypertrophy. 

This is a rare disease. It was first described by Duchenne in 1861, and 
since the attention of the profession was directed to it, cases have been ob- 
served on the Continent, in Great Britain, and in this country. Though 
our acquaintance with this disease is so recent, it has been fully and accu- 
rately described by various writers in our language. The Transactions of 
the London Pathological Society for 1868 contain a translated paper relat- 
ing to it, communicated by M. Duchenne, with photographic views, re- 
marks by Lockhart Clarke, and also the histories of two cases occurring 
in London, and exhibited to the Society by Adams and Hillier. In this 
country an elaborate paper has appeared on this form of paralysis, from 
the pen of Dr. Webber, of Boston, who succeeded in collecting the records 
of forty-one cases. {Boston Med. and. Surg. Journ., Nov. 17th, 1870.) 
And more recently Dr. Poore, physician to the New York Charity Hos- 
pital, collated the records of eighty-five cases, which furnish the material 
of an excellent monograph published in the New York Medical Journal 
for June, 1875. 

Weakness of the legs, and a peculiar waddling gait, are the first ob- 
servable symptoms, and by them we are able to ascertain approximately 
the date of the commencement of the paralysis. In 27 of the cases col- 
lated by Dr. Poore, the malady began so early in infancy that they were 
never able to walk like other children ; in 5 there is no record in regard to 
the time when the peculiar gait was first observed, or whether they ever 
could walk. Fifty-two, or about two-thirds of the cases, walked well at 
first, having no symptoms of the paralysis till after the age of two years. 
In 15 of these weakness of the legs and the peculiar gait were first ob- 
served between the ages of two and a half and five years ; in 23 between 
the ages of five and ten years ; in 6 between the ages of ten and sixteen 
years, and in 8 over the age of sixteen years. It is seen, therefore, that 
this malady is pre-eminently one of infancy and childhood. 

The gait, which is unsteady and waddling, has been compared to that of 
a duck. The child stands with the legs wide apart, and from the weakness 
of the legs, and unsteadiness of the gait, frequently stumbles and falls. In 
many cases this muscular weakness and difficulty in walking occur before 
there is any perceptible enlargement of the muscles beyond the normal 
size. 

The hypertrophy occurs without tenderness, pain, or other nervous 
symptoms, and without fever or constitutional disturbance. Occasionally 
the patient complains of stiffness or aching in the limbs, especially after 
exercise, even before the enlargement is observed, and exceptionally there 
is pain, even acute, in the legs. The hypertrophy is ordinarily observed 
first in the calf of one leg, and then in the opposite calf. In a case re- 
lated by Niemeyer, the muscles of the gluteal region were first affected. 



476 



PARALYSIS WITH PSEUDO-HYPERTROPHY, 



Fig. 21. 




In nearly all cases the gastrocnemii are hypertrophied. There were only 
two exceptions in the 85 cases collated by Dr. Poore ; but almost any ot 

the other muscles, or groups of muscles, may 
also be involved. The muscles which are 
most conspicuously affected, and which pro- 
duce the characteristic deformities, are those 
of the extremities and posterior aspect of the 
trunk. Spinal curvature, which is attributed 
to the weakened state of the erector muscles 
of the spine, appears early, and is seldom 
absent. The bending is such that a plumb- 
line, falling from the most posterior of the 
spinous processes, falls behind the plane of 
the sacrum, which is a means of distinguish- 
ing this disease from certain other spinal 
affections. The woodcut represents a case 
which came to the children's class at Bellevue, 
in April, 1872. The boy was two years old, 
and the mother stated that the peculiar gait 
and the enlargements had only been observed 
from four to six weeks, and yet the curvature 
of the spine was quite marked. Hed did not return to the class, and 
his subsequent history is therefore unknown. 

Of the muscles in the upper extremities the deltoid and scapular are 
the most frequently enlarged. Hypertrophy of the temporals has been 
observed in three cases, of the masseters in two, of the tongue in three, 
and of the heart in four (Poore). 

We shall see presently that atrophy occurs in the muscular element of 
the muscles which are affected, and that the hypertrophy is due to hyper- 
plasia of the connective tissue. Now occasionally this hyperplasia does 
not occur or is tardy in occurring, while the atrophy has taken place. 
Therefore, certain muscles may have less than the normal volume, which, 
from contrast with those which are hypertrophied, increases the deformed 
appearance. In ordinary cases the enlargement advances more rapidly 
and continues greater in the gastrocnemii, which are, as we have stated, 
the muscles first affected, than in other muscles, and therefore there is 
more prominence and hardness of the calves of the legs than elsewhere. 
In advanced cases walking is impossible, and the patient is obliged to re- 
main in a reclining- posture. Sometimes from the unequal muscular action 
the feet become extended and the toes flexed, so that the child in attempt- 
ing to walk steps on the anterior part of the sole of the foot, as in talipes 
equinus. 

In the first stages of the disease the electric contractility of the muscles 
is nearly normal, but in advanced cases response to the galvanic current 



ANATOMICAL CHARACTERS. 477 

becomes more and more feeble, according to the degree of atrophy of the 
muscular fibres. The skin retains its normal sensibility, with exceptional 
instances in which there is numbness either general or in places. Reddish 
or bluish mottling of the surface of the extremities is sometimes observed, 
which is attributed by some to obstructed venous circulation in the hyper- 
trophied muscles, and by others is supposed to be due to the peculiar 
neuropathic state. The bladder and rectum are not involved. The 
mental faculties are more or less blunted and feeble in certain cases, 
especially in those which commence in early infancy, but in some patients 
they do not seem to be materially impaired. 

Anatomical Characters. — There have been so few post-mortem ex- 
aminations of those who died having this disease, that it is still uncertain 
whether there is any centric lesion. Cohnheim examined the spinal cord 
in one case, and could find nothing abnormal. Recently, Mr. Kesteven 
has examined the brain and spinal cord from a case, and found dilatation 
of the perivascular canals, both in the brain and spinal cord, and also 
spots of granular degeneration chiefly in the white substance, " caused by 
loss of cerebral tissue replaced by morbid matter." {Jour, of Mental Set., 
Jan. 1871.) As this child was imbecile, it is not improbable that these le- 
sions were connected with the mental state, and not the muscular disease. 

Professor Charcot (Archiv. de Physiol., March, 1872) reports a careful 
microscopic examination of the spinal cord and of the nerves in a case 
whiclj had continued ten years. He could discover no deviation from the 
healthy state. More recently Dr. J. Lockhart Clarke examined a case 
and found the encephalon healthy, but in the spinal cord there was more 
or less disintegration of the gray substance in each lateral half, and in 
places dilatation of vessels, and commencing sclerosis {Medico-Chir. Trans., 
1874). 

It seems, therefore, that central lesions are not essential, and are some- 
times absent. When they do occur, it is probable that they are consecu- 
tive to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres and 
hyperplasia of the connective tissue which surrounds these fibres. The 
hyperplasia of the one element in the muscle is greater than the atrophy 
of the other, and hence the increase of volume above the normal size. 
The atrophy is probably a primary lesion, for muscular weakness ordi- 
narily occurs for a considerable time before there is any evidence of the 
enlargement, and, as Ave have seen, certain muscles may undergo the 
atrophy without ^he hyperplasia. Still the mechanical effect of the 
newly-formed connective tissue, doubtless, increases the atrophy in those 
muscular fibres which this tissue surrounds, and the comparatively quiet 
state of muscles in consequence of paralysis not only tends to promote the 
atrophy and degeneration of these muscles, but also of contiguous healthy 
muscles. 



478 PARALYSIS WITH PSEUDO-HYPERTROPHY. 

The muscles which are involved in this paralysis present a pale yellow- 
ish hue, resembling, says Niemeyer, the appearance of lipoma. Examin- 
ing by the microscope, we find in addition to. a large increase in the 
fibrous tissue and atrophy, and in some places disappearance of the mus- 
cular element, more or less fatty matter, granular and globular, occupy- 
ing the interstices. Mr. Kesteven describes as follows the appearance of 
the muscles in the case which he examined: "The muscular substance is 
pale, almost white, and very greasy. The superabundance of fat is evi- 
dent to the naked eye. The muscular fibres present the ordinary striation, 
but less distinctly than usual. The ultimate fibres are pale, and separated 
by a large increase of areolar and fibrous tissue." 

Causes Why there is this strange perversion of nutrition, so that 

there is an exaggerated development of the intermuscular connective 
tissue, and atrophy of the muscular fibres, is unknown. Boys are more 
apt to be affected than girls. Of the eighty-five cases embraced in the 
statistics of Dr. Poore, seventy -three were boys, and there was a similar 
excess of males in the cases collated by Dr. Webber. 

There is in a considerable proportion of cases the record of hereditary 
transmission, and in almost all the instances the predisposition is acquired 
from the mother's side. Thus in thirty-seven of Dr. Poore's cases "two 
or more belonged to the same family." In some instances three and even 
four maternal relatives had this form of paralysis. In one case observed 
by Duchenne, and in a few others subsequently observed, this malady 
seemed to be congenital, for the limbs at birth were unusually large, and 
the patients, when they came under observation, were unable to walk. 
No relation has been observed between this paralysis and syphilis, scrofula, 
or other diathesis diseases. 

Prognosis. — This disease is in most instances progressive, terminating 
fatally after a variable period. It is in its nature chronic, rarely ending 
in less than five or six years. A considerable proportion live longer, 
some even attaining adult age. The paralysis may be stationary for a 
time, but afterwards continue to increase. Duchenne has reported one 
case of recovery. In two or three other instances patients appeared to 
improve somewhat under treatment, but the writers admit they may have 
become worse afterwards. Death is apt to occur, not directly from the 
paralysis, but from some intercurrent disease, especially of the lungs. 

Treatment The treatment thus far employed has been chiefly local, 

consisting in the use of electricity, and kneading or shampooing over the 
affected muscles. Both the primary and induced electrical currents have 
been employed, but, unfortunately, without any appreciable benefit in 
most cases. Benedikt, who claims a better result from electrization than 
any other observer, applied the copper pole over the lower cervical gan- 
glion, and the zinc pole along the side of the lumbar vertebrae by means 
of a broad metallic plate. 



DISEASES OF SPINAL CORD AND ITS MEMBRANES. 479 



CHAPTER XVII. 

DISEASES OF THE SPINAL CORD AND ITS COVERINGS. 

The diseases of the spinal cord, and of the parts which cover and pro- 
tect it, are important, but they are less understood than are those of any 
other portion of the body. This is partly due to the fact, that in many cases 
the spinal disease coexists with a similar pathological state of the brain 
or its meninges, the symptoms of which predominate and mask those which 
pertain to the spine, partly to the fact that the chief symptoms of spinal 
disease are often located in organs or parts which are at a distance from 
the spine, and lastly, to the fact that it is difficult, for obvious physical 
reasons, to determine the exact state of the spine at the bedside ; while 
post-mortem inspection of the spine, which alone can give accurate patho- 
logical knowledge, is less frequently made than of any other organ. 

Certain spinal diseases occurring in childhood are the same as in adult 
life, presenting identical symptoms and lesions in the two periods, and 
therefore they require no extended notice in this treatise. Others are 
common to childhood and maturity, but they present peculiarities in the 
former period, which require to be pointed out, while others still are 
peculiar to childhood. 

Spinal irritation is not infrequent in delicate and poorly-fed children. 
I have from time to time observed marked cases of it in the class in the 
Outdoor Department of Bellevue, the patients usually being above the 
age of three or four years, and exhibiting evidences of cachexia. Most 
of them have been spare and pallid, some affected with a nervous cough or 
palpitation, and some with neuralgic pains in the chest, abdomen, or else- 
where, which pressure at a certain point upon the spine intensified. These 
cases recover by better feeding, outdoor exercise, mild counter-irritation 
along the spine, and the use of tonics, especially of iron. 

Primary inflammation of the cord and its meninges is rare in children. 
Secondary inflammation of these parts is, on the other hand, more common 
in children than in adults. It is common in caries of the vertebrae, and 
in cerebro-spinal fever. The preponderance in functional activity of the 
spinal cord, and the feeble controlling power of the brain, render child- 
hood more liable to convulsions and reflex paralysis than any other period 
of life. Until within a recent period, most cases of infantile paralysis 
were believed to be reflex, due to dentition, intestinal irritation, etc., but 
it is now attributed to congestion of the spine, or to disease of the nervous 
filaments at the seat of the paralysis. Still there are cases of true reflex 



480 



CONGESTION OF SPINAL CORD, ETC. 



paralysis in children, in regard to the etiology of which there can be no 
doubt. Prof. Sayre of this city has called attention to the fact, that 
balanitis and preputial adhesions sometimes cause paraplegia, more or 
less pronounced, in young children, and which is relieved by dividing the 
adhesions, and restoring the mucous surface of the glans and prepuce to 
its normal state. Such a case was brought to the children's class in the 
Outdoor Department at Bellevue, in April, 1875. The child could not 
walk, or scarcely stand, without support, but after the division of the 
adhesions, and subsidence of the inflammation, locomotion rapidly im- 
proved. 1 It is well known that masturbation sometimes causes a similar 
weakness of the lower extremities. Dr. West relates the case of a child 
" between two and three years old," who began to totter in his gait, and 
finally almost ceased walking. He was observed to practise masturbation. 
" This was put a stop to," and he soon recovered his health and his 
power of locomotion. (Diseases of Children, page 146, 4th American 
edition.) 

Congestion of the Spinal Cord and its Membranes. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. 
It may be active or passive. Active congestion, occurring independently 
of meningitis or myelitis, is in most instances transient, and subordinate 
to some graver disease, in the course of which it arises. It is probably 
often overlooked. It is not fatal, and its symptoms are frequently masked 
by those which are referable to the brain or some other organ. It is be- 
lieved to be common in the initial period of certain of the fevers of child- 
hood. It is not improbable that the hyperesthesia observed upon the 
thoracic and abdominal surfaces and along the thighs, in the commence- 
ment of remittent and certain other febrile diseases, have their origin in a 
congested state of the spine. To this congestion writers attribute the 
lumbar pain and occasional paraplegia in the initial stage of variola. 
Active spinal congestion may also result from the sudden impression of 
cold, and to it, as has been stated above, most neuropathists attribute 
those sudden attacks of paralysis which are peculiar to infants, and which 
have therefore been designated infantile paralysis. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges, to wit, the tortuousness of their 
veins, and the absence of valves in these veins, the lack of muscular sup- 

1 Some months since I requested Drs. Holgate and Bosly, attending physicians 
in the children's class at Bellevue, to make examination of the state of the prepuce 
in infancy. They report that they have found preputial adhesions almost daily, 
in most instances withput symptoms, but sometimes with dysuria, and only in 
rare instances with paralysis. 



ANATOMICAL CHARACTERS — SYMPTOMS. 481 

port of the vessels, and the inferior position of the spine in sickness as the 
patient lies quietly in bed. A common cause of passive congestion of 
these parts is some protracted and enfeebling disease, which diminishes 
the contractile force of the heart (cardiac paresis), producing congestion 
of the spinal cord in the same manner as under similar circumstances 
hypostatic congestion of the lungs occurs. Severe convulsive diseases, as 
tetanus or eclampsia, when protracted or occurring at short intervals, 
commonly produce spinal congestion. In tetanus, this congestion is ex- 
treme, so that extravasation of blood is apt to occur from the engorged 
vessels, especially from those of the pia mater. 

Anatomical Characters It is often impossible, at post-mortem 

examinations, to determine how much of the congestion of the spine and 
its meninges is pathological, and how much cadaveric; since, if the corpse 
is placed on its back at death, a very considerable engorgement of the 
spinal vessels occurs from gravitation of blood. If the body has been 
placed on the side or face, this cadaveric congestion is prevented. Since, 
in active congestion, the arterioles and capillaries are distended with arte- 
rial blood, the color is a brighter red than in passive congestion, in which 
venous blood predominates. Active congestion of the cord usually coexists 
with that of the meninges, but it may occur without it. In cases of con- 
siderable congestion, the " puncta vasculosa" appear upon the incised 
surface, both of the white and gray substance. If the congestion be pro- 
tracted, or if it recur frequently, it may produce permanent dilatation of 
the arterioles and capillaries, in greater or less degree, and it may also 
lead to sclerosis of the cord. Passive congestion seldom, perhaps never, 
occurs in the cord; without being equally and often to a greater extent 
present in the meninges. Continuing for a time it gives <rise to transuda- 
tion of serum into the interspaces over the cord, and even softening of the 
cord may occur to a limited extent from imbibition of serum. In either 
form of congestion, extravasations of blood are frequent. 

Symptoms — Spinal congestion is announced by pain in the region of 
the spine, usually in the lumbar, or dorsal and lumbar portions, and irradi- 
ations of pain, and tingling in the legs. In addition, more or less paraly- 
sis of the bladder and legs may occur. The paraplegia may occur early 
or not till the lapse of several days. In active congestion, the symptoms 
are rapidly developed, and they attain their maximum intensity sooner 
than in the passive form. In passive congestion the development of symp- 
toms is not only more gradual, but they are ordinarily less pronounced, 
and are attended by more fluctuations than in the active form. The para- 
lysis, if present, comes on slowly after several days and is incomplete. 
Spinal congestion, especially of the passive form, is apt to be associated with 
cerebral congestion, as for example in tetanus and severe eclampsia, and 
the spinal symptoms therefore coexist with those which have a cerebral 
31 



482 

origin. The duration and the result of a hypergemic state of the spinal 
cord and its meninges, depend largely on the nature of the cause. If it is 
not relieved within a few days, there is strong probability that some other 
serious pathological state lias supervened, as meningitis, myelitis, extrava- 
sation of blood, or serous transudation, with softening of the nervous 
substance. 

Treatment In the adult, spinal congestion sometimes results from 

the sudden cessation of the hemorrhoidal or catamenial flow, and the ap- 
plication of leeches or wet cups along the spine is indicated. But in the 
child, the abstraction of blood is seldom required. Nor is the application 
of cold along the spine ordinarily advisable, since it promotes congestion 
of the internal organs, and its debilitating effect is prejudicial to most 
children who have spinal congestion, since, in most forms of this malady 
occurring in childhood, sustaining treatment is required. In active hyper- 
emia, laxatives are often useful, and rubefacient applications should be made 
along the spine, as by mustard, or by friction with a stimulating liniment. 
In the inflammatory spinal congestion of cerebro-spinal fever, I have em- 
ployed with a very satisfactory result a liniment containing equal parts of 
camphorated oil and turpentine. In both active and passive hyperemia 
lateral decubitis should be prescribed rather than dorsal. The internal 
use of ergot, in order to diminish the turgescence of the spinal vessels, has 
not been attended by such benefit as to justify us in recommending it. 
On the other hand, bromide of potassium is a remedy of real value, but it 
is more useful in certain cases than in others. It is signally beneficial in 
those cases in which there is also cerebral congestion. When the conges- 
tion is increased or produced by clonic convulsions, the bromide is the 
most reliable remedy which we possess for the removal of the cause. Thus 
it should be employed in the treatment of the spinal and cerebral conges- 
tion in the commencement of variola, in which convulsions are so common, 
and in the convulsions of pertussis, which cause extreme passive congestion 
of the cerebro-spinal axis. Passive congestion of the spine, common in 
exhausting diseases, and due to feebleness of the circulation, is best treated 
by stimulating and sustaining remedies, and by the lateral decubitus. It 
is hypostatic, and may be associated with a similar congestion in the pos- 
terior part of the lungs. 



SPINA BIFIDA, 



483 



CHAPTER XVIII. 



SPINA BIFIDA. 



This is one of the most common of the malformations. In its severe 
form it is from its nature incurable, admitting only of palliative treatment, 
while in its milder forms, it may be cured, or so relieved as not to compro- 
mise life. The term spina bifida is applied to a hernia of the spinal 
meninges, which produces a rounded tumor, situated posteriorly over the 
spine in the median line. It is due to the congenital absence or incom- 
pleteness of one or more of the arches of the vertebrae. In exceptional 
instances, the arch is said to be complete at birth ; but the lateral portions 
separate, and are pressed outwards during the first weeks of life. The 
tumor contains the cerebro-spinal fluid, and unless it is small, and its walls 
are unusually thick, fluctuation may be detected in it. When the child 
cries the tumor enlarges, and it is reduced by compression, the fluid re- 
entering the spinal canal. If the tumor is large, its complete subsidence 
by pressure is apt to produce dangerous cerebral symptoms. Spina bifida 
is the counterpart of hydrocephalus, and the two often coexist. If we com- 
press the hydrocephalic head, the spinal tumor increases, and vice versa. 

Fig. 22. 




Club-foot is another not infrequent complication. In the case which is 
represented in the accompanying wood-cut, hydrocephalus, spina bifida, 
and club-foot coexisted. The child was brought to the children's class 
in the Outdoor Department at Bellevue, and after a few visits I lost sio-ht 



484 SPINA BIFIDA. 

of it. It probably died soon after, since the tumor, over which the 
cuticle was wanting, presented a deep-red appearance as if inflamed, so 
that ulceration and escape of the fluid seemed near at hand. There is 
ordinarily but one spina bifida, the common seat of which is the lumbar 
region, but occasionally there are two or more. If the aperture through 
which the tumor protrudes is small, it is usually pedunculated, but if large, 
it is sessile. In some patients it is covered by skin which may be normal 
or somewhat indurated ; in others the skin is absent over the entire tumor 
or its most prominent part, and the dura mater or the connective tissue 
lying directly over the dura mater is exposed, and is liable to inflamma- 
tion from friction. If the walls of the tumor are thin the liquid may trans- 
ude in drops, and they are apt to give way by ulceration or rupture. Sud- 
den escape of the liquid, and collapse of the spina bifida, involve great 
danger, for convulsions, coma, and death are the probable result. 

The relation of the spinal cord or nerves, or of the cauda equina, to the 
tumor, is a matter of great importance. In many patients the adjacent 
portion of the cord or cauda equina, is deflected through the aperture, and 
lies against the interior of the sac. Spinal nerves also not infrequently 
lie within the sac, some returning into the spinal canal, and others passing 
through the walls of the sac to their points of distribution. Those which 
are deflected into the tumor and return into the canal obviously lie lowest. 
In the most favorable cases, namely, those with a small aperture, or small 
tumor, or a narrow and long peduncle, neither the cord, cauda equina, nor 
nerves lie within the sac. It is important to the practitioner to bear in 
mind that in all probability, unless under the favorable anatomical cir- 
cumstances stated above, the sac contains nervous elements. In rare 
instances the liquid, instead of lying externally to the cord, lies within its 
central canal. The substance of the cord then becomes distended, and 
it incloses the liquid like a delicate sac, just as the hemispheres of the 
brain are unfolded and expanded in the common form of congenital 
hydrocephalus. As might be expected from the anatomical characters of 
the more serious forms of spina bifida, paralysis, more or less complete, 
of the vesical and rectal muscular fibres, and paraplegia sometimes occur, 
in which event the fatal issue is probably not far distant. 

Diagnosis This is easy in ordinary cases. The congenital nature of 

the tumor, and the bony edge of the aperture, appreciable to the touch, 
suffice in ordinary cases to establish the diagnosis. The diminution of the 
tumor by pressure, and its enlargement when the child cries, are important 
diagnostic signs. There are various lumbo-sacral tumors located in the 
median line, from which it is important that spina bifida should be diag- 
nosticated. Sometimes a cyst occurs in this situation which was originally 
a spina bifida, but obliteration of the canal in the pedicle occurred, just as 
the canal connecting a hydrocele with the abdominal cavity closes. Solid 
congenital tumors sometimes also occur in the same situation, among 



PROGNOSIS — TREATMENT. 485 

which, as most common, may be mentioned fatty tumors, and tumors con- 
taining foetal remains. The most common seat of tumors which inclose 
foetal remains is at the point where spina bifida ordinarily occurs. Physi- 
cians have erred in confounding these tumors, as well as those which con- 
sist of fat, with spina bifida ; but a mistake in diagnosis can only occur 
through haste or carelessness of examination. 

Prognosis This is in most instances unfavorable. Ordinarily the 

tumor increases slowly? and finally the sac gives way by ulceration or rup- 
ture ; the liquid escapes, and death occurs in convulsions and coma ; or, 
if the escape of the liquid is prevented by pressure, and the aperture 
closes, a second rupture is probable with a fatal result. In other cases the 
tumor may not rupture, but the cord is softened, or it is injured by the 
abrupt bend, so that paraplegia results, and death after a time occurs in a 
state of emaciation. Rarely the tumor may shrivel away by absorption 
of the liquid, and the disease is cured, or so nearly cured that it gives no 
inconvenience, and the patient lives for years. In other rare instances the 
tumor may remain without any material change, and without giving rise 
to symptoms. The spina bifida being small and covered with skin, and 
the aperture leading from it into the spinal canal being also small, the 
patient lives through the natural period of life with little inconvenience. 

Treatment It is evident, from what has been stated, that no fixed 

rule can be laid down for the treatment of the spina bifida. In the most 
favorable cases, in which no symptoms occur, and there is no indication 
that the tumor will change or undergo any unfavorable change, surgical 
treatment is not required, except the application of a soft pad to support 
the tumor, to prevent its injury by friction. Indications which justify 
active surgical interference are growth of tumor, absence of skin from it, 
with tension of the parietes, so that an early rupture is inevitable, and 
dangerous nervous symptoms, as convulsions or paraplegia. 

From the nature of spina bifida it is evident that operations upon it 
must be conducted with caution. The usual presence of the spinal cord 
in the pedicle and in the sac forbid ligation and excision, and render 
hazardous attempts to obliterate the sac by producing inflammation within 
it. A safe mode of treatment, but not the most efficient, is to puncture 
the sac and withdraw a portion of the liquid by a grooved needle or hypo- 
dermic syringe. A soft pad should then be applied to produce gentle 
compression. If no unfavorable symptoms occur, the puncture may be 
repeated after a day or two. This operation has been employed with a 
satisfactory result by Sir Astley Cooper among others ; but, simple as it 
is, it is not devoid of danger, for the removal of the liquid, if carried 
beyond a certain point, may produce dangerous nervous symptoms, espe- 
cially convulsions. In performing the operation, the puncture should never 
be made in the median line, on account of the danger of wounding the 



486 SPINA BIFIDA. 

cord, which lies against the median portion of the sac. The veins, also, 
should be avoided. 

Another mode of treatment is by iodine injections. They are preferable 
to other methods, if the neck is long and pedunculated, so as to be easily 
compressed. If the tumor is sessile, and the aperture into the spinal canal 
is free, these injections involve great danger, and are not to be recom- 
mended ; for more or less of the solution will inevitably enter the spinal 
canal, and give rise to spinal meningitis. Iodine injections have been 
employed with success by Professor Brainard, of Chicago, who states that 
he " perfectly and permanently cured" three of seven cases ; and by Vel- 
peau, of Paris, by whose method five in ten operations were successful, 
and by many others. Professor Brainard withdrew some of the liquid 
contents, and then injected half an ounce of water containing 2J grains of 
iodine, and 1\ grains of iodide of potassium. In a few seconds this was 
allowed to flow out, and the sac was then washed out with tepid water. 
Then a portion of the cerebro-spinal fluid, which had been kept warm, 
was returned into the sac. When he had withdrawn six ounces of this 
fluid he returned two ounces. In employing the iodine, or any other irri- 
tating injection, it is necessary to compress the pedicle, so that the liquid 
does not enter the spinal canal. Velpeau employed one part of iodine, 
one of iodide of potassium, and ten of distilled water. 

During a debate in the Soeiete de Chirurgie, M. Debont recommended 
the evacuation of only a little of the fluid, and the injection of two or three 
drops of the tincture of iodine diluted with an equal quantity of water ; 
and T. Smith, by the injection of one drop of the tincture, produced an 
amount of inflammation which nearly obliterated the sac (see Holmes's 
Surg. Dis. of Children'). Since statistics show so good a result of iodine 
injections, this mode of treatment seems preferable to any other for certain 
cases, and as one drop has produced general inflammation of the sac and 
nearly obliterated it, it seems safest and best to begin with so small a 
quantity. 

If there is reason to believe, from the small size of the orifice and other 
anatomical characters, that neither the cord, cauda equina, nor any of the 
spinal nerves, lie within the sac, it may be thought best to remove the 
tumor. It has, indeed, been proposed to open the tumor, immersed under 
warm water sufficiently to observe the relation of the nervous elements, 
and to press them back gently into the canal if they lie within the sac. 
If it is decided to remove the spina bifida, a clamp, or elastic band, is 
placed around the pedicle so snugly as to cause firm adhesion of the walls 
of the pedicle, and excite sufficient inflammation in them to produce 
agglutination, but without causing strangulation Or suppuration. 

After a time, perhaps two or three days, when it is evident that agglu- 
tination has occurred from the fact that the liquid cannot be returned 
within the spinal canal by compressing the sac, the tumor may be removed 



VERTEBRAL CARIES. 487 

by the knife or ecraseur. Statistics do not show so favorable a result of 
this operation as of the iodine treatment, and the reason is obvious, for it 
is only in exceptional cases that the tumor can be removed without injury 
to the nervous tissue, and excision of a portion of the cord, or of important 
nerves, either produces death or a condition to which death would be a 
relief. 

Spina bifida has also been treated by opening the sac on its side, pressing 
back the spinal cord or its nerves into the spinal canal, uniting the edges 
of the wound, and then applying pressure to prevent protrusion, but the 
result has not been favorable. Treatment by simple puncture, followed by 
compression, and if it fail, as it probably will, the cautious use of iodine 
injections, is the preferable mode of treating ordinary cases of spina bifida, 
which require surgical interference. 



CHAPTER XIX. 

VERTEBRAL CARIES. 

Vertebral caries, designated also Pott's disease, occurs chiefly in 
childhood, but now and then adults are affected with it. It is an osteitis 
of the bodies of one or more vertebrae, ending in their ulceration and a 
lifelong deformity, if not checked. 

Causes. — A reduced state of system, and especially the scrofulous dia- 
thesis, strongly predispose to caries. Hence this malady is more common 
in the city than in the country, where better hygienic conditions produce 
a more vigorous constitution. Masturbation has also been assigned as a 
cause. It certainly may be a predisposing cause from its lowering effect 
upon the system. In certain cases, there is no apparent exciting cause, 
while in others there is the history of a fall upon or some injury of the 
spine. 

Vertebral caries may occur in the cervical, dorsal, or lumbar portions of 
the spinal column, but it is more common in the lower dorsal than else- 
where. With the development of the osteitis, the body of the vertebra 
which is affected, becomes hypersemic, and the spongy tissue is soon infil- 
trated with blood and pus. The bone becomes swollen and softened, and, 
therefore, less resisting than in the healthy state, so that it yields under 
the weight of the shoulders and head, which it sustains. Therefore, after 
the osteitis has continued a certain time, there begins to be posterior con- 
vexity or rather angularity of the spine, for while the vertebral bodies 
soften and yield by the weight above them, the arches retain their integrity 
and firmness, and are unyielding. 



488 VERTEBRAL CARIES. 

Much of the tediousness and suffering of this malady is due to the fact 
that the inflammation is so deep-seated, and a healthy bony barrier is in- 
terposed between it and the surface, so that there is no ready escape of the 
pus. It permeates the spongy tissue, filling the cavities produced by the 
softening and absorption of the bone-substance. If the inflammation is of 
small extent, the amount of pus small, the constitution good, and if the 
disease is early recognized and properly treated, the child may recover 
without any fistulous opening, by absorption of the pus, and with little re- 
maining deformity. 

In the large proportion of cases, however, the history is different. The 
disease is not recognized till the stage of deformity, the caries is so exten- 
sive and the pus so abundant, that it escapes between the vertebras, form- 
ing an abscess external to them, which connects with the interior of the 
vertebras by a fistulous canal. This abscess if in the cervical region may 
press upon the pharynx or oesophagus, or upon the air-passages, producing 
dangerous obstruction to the respiration. (See Art. Eetro-pharyngeal 
Abscess.) The pus may point and discharge externally near the seat of 
the caries, but in a large proportion of instances it takes a long and cir- 
cuitous route to the surface, or it opens internally. There are instances 
in which it discharges into the pleural or abdominal cavity, or into one of 
the abdominal organs. If, as is sometimes the case, it establishes a con- 
nection with the intestine and escape in the stools, the result will probably 
be favorable. In other instances it descends into the pelvic cavity, and 
finds an outlet by the inguinal ring, or sciatic notch, or it enters the sheath 
of the iliacus or psoas muscle, and points externally. 

When the disease ends favorably, new bone is thrown out around the 
diseased vertebras, preventing any further bending, and giving stability to 
the spine. If the abscess do not discharge, but remains subcutaneous, 
Billroth says : . . . " While the bone disease recovers most frequently, a 
large part of the pus, whose cells disintegrate into fine molecules, is 
absorbed, while the inner walls of the abscess change to a cicatricial tissue, 
which in the shape of a fibrous sac contains the puriform fluid. Such pus- 
sacs often remain in this stage for years." 

If the pus has escaped externally, the abscesses and fistulas contract and 
finally close, their site being occupied by condensed connective tissue. The 
portions of the diseased vertebras which have retained their vitality are 
enveloped and supported by the new bone, so that the part of the spine 
which was the seat of the disease, though anchylosed and curved, has 
greater firmness than in health. 

The history of unfavorable cases varies; the caries may extend. Pus 
finding no vent may accumulate in cavities and sinuses, in which detached 
portions of bone float, or it may make its way in such directions, that it 
produces alarming complications, and impairs or obstructs the functions of 
important organs. 



SYMPTOMS. 489 

Spinal meningitis in the vicinity of the caries, and due to extension of 
the inflammation, is common, and " the spinal medulla," says Billroth, 
" may be endangered by participation in the suppuration, or by being so 
bent by the inclination of the vertebras, that its function is destroyed." 
Hence the paralysis of the lower extremities, bladder, and rectum, which 
occurs in aggravated cases, and which entails a fatal issue. In a certain 
proportion of cases the blood becomes more and more impoverished from 
the continuance of the inflammation and suppuration, and death occurs in 
a state of exhaustion. In such cases post-mortem examination often dis- 
closes waxy degeneration of important organs, as the spleen, liver, kid- 
neys, and intestines, for it is well known that chronic suppurative inflam- 
mation of the bones is one of the two chief causes of the waxy disease, 
syphilis being the other. 

Symptoms. — Caries of the vertebrae is often preceded by symptoms or 
appearances which are due to the strumous cachexia. Strumous ailments 
have probably occurred in the patient, or in members of the family, 
or without any clear history of struma, the child has perhaps for some 
time been in failing health. In cases which I have observed, one of the 
chief symptoms, and sometimes almost the only symptom in the com- 
mencement of the caries, has been neuralgic pain, usually not severe, in- 
termittent, or more or less constant, at some point in the anterior aspect of 
the body, most frequently in the chest, epigastric or umbilical region. This 
pain has been present in a larger proportion of cases, than pain in the 
spinal region at the seat of the caries, though Guersant dwells particularly 
upon the latter as a symptom of caries. Patients with this neuralgia are 
not infrequently treated for indigestion, or worms, the true nature of the 
malady not being suspected, and the spine not even being examined. 
This neuralgia seems to be due to compression of the spinal nerves, by 
inflammatory exudation at the points where they emerge from the spinal 
canal. I can recall to mind a number of cases, in which I have on dif- 
ferent occasions been asked to prescribe for this neuralgia, which was 
shown by the sequel to be undoubtedly the result of vertebral caries, and 
yet with a careful examination of the spinal column could discover no evi- 
dence of disease at any point. After a time, tenderness, pain, and inflam- 
matory induration, appreciable to the touch, may occur in the spine, but 
not usually till the malady is well advanced. Lassitude, fatigue after 
slight exertion, poor appetite, with slight fever, are common symptoms in 
the first stage of the caries. 

As the case advances, if the nature of the disease is not recognized, and 
no artificial support of the trunk is provided, the child instinctively seeks 
some way of supporting the head and shoulders. He rests his head upon 
his hands, or his elbows upon the table. Soon a gibbosity or angularity ap- 
pears, affording clear and positive proof of the nature of the disease. Even 
now there is little or no tenderness when pressure is made directly on the 



490 VERTEBRAL CARIES. 

spine, but it is observed more when pressure is made laterally upon it. If 
the inflammation extends so as to involve the meninges and the cord, prick- 
ing, tingling, numbness or weakness of the legs may occur, which are symp- 
toms of grave import, for it is probable that the case will end in para- 
plegia and death. A state of emaciation and general weakness, sometimes 
accompanied by diarrhoea and oedema of the limbs, precedes death. But 
a very considerable degree of curvature is not incompatible with a healthy 
and normal performance of all the functions, and the number who recover, 
and lived to an advanced age with great deformity, is large, as every one 
knows. 

Diagnosis This is often from the nature of the disease obscure and 

uncertain for a time. The long continuance of pain in the chest or abdo- 
men, or perhaps in the thighs, without any cause, which we can detect, 
located at the seat of the pain, should excite suspicion of spinal disease. 
Such pain may be produced by spinal irritation, but in this malady pressure 
on the spine is badly tolerated, and when we touch a certain part, the neu- 
ralgic pain is intensified. In caries, as we have seen, firm pressure upon 
the spine is tolerated, and it does not increase the neuralgia. At a later 
period in caries, there may be spinal pain and tenderness, but there is now 
also spinal deformity, by which alone the diagnosis is clearly established ; 
stiffness observed in the movements of the spine, pain in the spine, on 
sudden movement or jarring the body, impaired appetite and general 
health, and instinctive desire to sit or recline in such a way as to relieve 
the spine partially of the weight of the head and shoulders, are symptoms 
which, if they coexist, afford very strong evidence of the presence of caries, 
although there is as yet no deformity. 

The spinal deformity of rachitis is distinguished from that of caries, by 
the fact, that it occurs slowly without pain or tenderness, and is rounded 
instead of angular. Moreover, the rachitic diathesis precludes scrofulous 
ailments, and the scrofulous diathesis rachitic ailments, as the two diatheses 
do not coexist or but rarely ; so that if there are in the state of the patient 
or have been in his history evidences of scrofula, the presumption is that 
the bending of the spine occurs from caries. In a case of rachitic curvature, 
we find also enlargements of the ankles and wrists, keel-shaped thorax, 
prominent abdomen, rachitic head, etc. 

Prognosis The course of this malady, even when the caries is slight 

and the symptoms mild, is tedious. In the most favorable cases, the 
general health is but slightly impaired, the caries confined to one vertebra, 
and is early diagnosticated and properly treated. On the other hand, if 
the general health is decidedly poor, the child anaemic and wasted, the 
curvature great, and an abscess has occurred, the case is very serious. 
Between these two extremes is every grade. The prognosis is more 
favorable in the child than in the adult. The few adults whom I have 
seen with it all died. It is less favorable in the cervical region than in 



TREATMENT. 491 

the dorsal or lumbar. A mild case occurring in a good condition of health, 
may become grave and even fatal by neglect and improper treatment. A 
majority of the patients, if the disease is not too far advanced when recog- 
nized, recover if properly treated, but the deformity which results may 
prove serious in after-life. The incomplete expansion of the lungs in the 
humpbacked, greatly increases the danger and the dyspnoea in bronchitis 
and pneumonia, and if the caries has been at a low point in the spine, and 
the patient a female, the deformity will probably present an obstacle to 
childbearing. 

Treatment The treatment must be constitutional and local, hygienic, 

medicinal, and mechanical. It is of the utmost importance to improve the 
general health, as it is in all chronic inflammations and scrofulous ailments. 
Pure air, sunlight, personal cleanliness, and plain but the most nutritious 
diet are required. Tonic and anti-strumous remedies are indicated. To 
many patients I have prescribed, three times daily, cod-liver oil, to which 
the syrup of the iodide of iron was added, giving two drops to a child of 
one year, and one additional drop for each additional year. The judicious 
use of alcoholic stimulants will often be found useful, if the appetite is poor 
and general health seriously impaired, as will also the vegetable bitters. 

In all strumous inflammations of the bones, which extend to or involve 
joints, and which are in their nature chronic, perfect quiet of the parts, so 
far as it is consistent with the degree of exercise which is required in order 
to improve the appetite and general health, is indispensable for successful 
treatment of the case. The patient with this malady should be encouraged 
to lie much of the time in bed, for the double purpose of preventing move- 
ments of the inflamed vertebras, and of relieving them of the weight of the 
shoulders and head. Bat confinement in bed is badly tolerated, and exer- 
cise is necessary for a healthy functional activity of the organs ; therefore 
mechanical support of the spine is required. The apparatuses which have 
been invented for the purpose of supporting the spine and rendering it im- 
movable, and of sustaining the head, if the caries is in the cervical region, 
or the head and shoulders, if it is in the dorsal or lumbar region, are in- 
genious and effectual. Some of them are rather cumbersome, but others 
are sufficiently light for the youngest child who can walk. The apparatus 
should be worn for months, care being taken to prevent excoriation or un- 
due pressure upon any point. It may be removed at night, and reapplied 
on rising in the morning. 



SECTION II. 
DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 
CORYZA. 

The term coryza is applied to inflammation of the Schneiderian mem- 
brane. It is acute or chronic. The acute form is primary or secondary. 
Acute primary coryza is common in infancy and childhood. Its usual 
cause is exposure to currents of air, to cold, and especially to sudden 
changes of temperature from warm to cold. The cause is the same as 
that in the ordinary forms of bronchitis. These two diseases frequently 
indeed coexist, occurring from the same exposure. The inflammation in 
such cases commences upon the Schneiderian membrane, immediately 
upon the operation of the cause, and soon after extends to the bronchial 
tubes. Acute coryza may also be produced by the inhalation of irritating 
vapors, hot air, or dust, and also by the presence of a foreign body, as a 
button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The diseases in 
connection with which it occurs are hooping-cough, measles, scarlet fever, 
diphtheria, and constitutional syphilis. In the infant, coryza is one of 
the first manifestations of hereditary syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two weeks. The 
secondary form gradually declines, in most cases, when the primary affec- 
tion on which it depends is cured. Syphilitic coryza is more protracted 
than the primary form, or than that accompanying the eruptive fevers. 
Some children are so liable to coryza that it occurs whenever they take 
cold. Occasionally it is so frequently renewed in the winter months that 
it resembles the chronic form of the disease. 

Chronic coryza is commonly dependent on a dyscrasia. It corresponds 
with chronic inflammation of the external ear, and otorrhoea is not infre- 
quent in connection with it. The dyscrasia is indicated by pallor, flabbi- 
ness of the flesh, and liability to glandular swellings. Chronic coryza 
may also occur in those who have good general health, as the result of an 
acute attack. Many a case dates back to one of the exanthematic fevers, 



ANATOMICAL CHARACTERS — PROGNOSIS. 493 

the local affection continuing after the general health is restored. Rarely 
chronic coryza comes on gradually and without appreciable cause. 

Anatomical Characters.— The alterations which the nasal mucous 
membrane undergoes when inflamed, vary considerably in different cases. 
In the simplest and most common form of coryza, this membrane is some- 
times in patches, sometimes generally reddened, thickened, and softened. 
Its papilla? are prominent, producing an inequality of the surface. Ulcer- 
ations are not common in simple acute coryza, but they sometimes occur 
in the chronic form. 

In diphtheria, and sometimes in scarlet fever and variola of severe type, 
the coryza is pseudo-membranous, and when it presents this form it is 
commonly but not always associated with pseudo-membranous angina or 
laryngitis. A case of pseudo-membranous coryza occurring in measles is 
related by M. Guibert. The patient was a rachitic boy, three and a half 
years old. The pseudo-membrane, in grave cases, may cover almost the 
entire surface of the nostrils, but ordinarily it occurs in patches. 

Symptoms The constitutional symptoms are mild or severe, according 

to the gravity of the inflammation. If the coryza is acute and pretty 
general, there is febrile movement, with thirst and loss of appetite. 
Frontal headache is common, from the proximity of the inflammation to 
the head, or its extension to the frontal sinuses. Sneezing is the first 
symptom in many cases of acute coryza. As the inflamed membrane 
swells, more or less obstruction occurs to respiration. The breathing is 
noisy, especially during sleep, and in severe cases the patient is compelled 
to breathe mostly through the mouth. If there is much obstruction to 
respiration the suffering of the patient is considerable, from the sensation 
of fulness in the nostrils, the headache, and the muscular effort required 
in each respiratory act. 

In the commencement of coryza the patient experiences a sensation of 
dryness in the nostrils, which is soon succeeded by a thin discharge of a 
serous appearance. In the course of a few hours the secretion becomes 
thicker. It is muco-purulent, and remains such till the disease begins to 
decline. Inspissated mucus and crusts are apt to collect within the nos- 
trils and around their orifice in chronic coryza, and sometimes also in the 
acute disease, if the discharge is not abundant. These crusts increase the 
difficulty of breathing. Often the acridity of the discharge is such that 
the skin of the upper lip and around the nostrils is excoriated. 

Prognosis — Uncomplicated catarrhal coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may seriously 
interfere with lactation. Coryza, accompanying the eruptive fevers, al- 
though it may increase the suffering, does not materially increase the 
danger. Syphilitic coryza subsides when the system is sufficiently affected 
by antisyphilitic remedies. Chronic coryza is sometimes very obstinate. 



494 CORYZA. 

It may continue for months or years, giving rise to a constant, but often 
not abundant, discharge. 

Treatment Common mild attacks of coryza require little treatment. 

The bowels should be kept open, the feet soaked in mustard-water, and the 
body should be warmly clothed. Inunction of the nostrils is a popular 
remedy, and it seems to give some relief. If coryza commence with symp- 
toms which indicate a pretty severe attack, and there are evidences of 
extension of the disease towards the bronchial tubes, an emetic of syrup of 
ipecacuanha, given at an early period, moderates the severity of the in- 
flammation and may prevent the occurrence of bronchitis. Afterwards a 
simple diaphoretic mixture, as the following, should be given : — 

I£. Syrupi ipecacuanha?, 5ij > 
Spirit, aether, nitr., 3J > 
Syrupi simplicis, ^ij. Misce. 

One teaspoonful every three hours to a child of six months. In place 
of sweet spirits of nitre, acetate of potash may be employed in the dose of 
one to two grains for infants ; and if there is decided febrile reaction, from 
half a minim to two minims, according to the age, of tincture of digitalis, 
should be added to each close. 

A three to five per cent, solution of common salt in warm water injected 
into the nostrils with a small syringe, aids materially in removing the 
muco-pus which obstructs the respiration, and in establishing a healthier 
state of the inflamed surface. I have employed in the same way, with 
apparent benefit, carbolic acid, glycerine and water, with or without a few 
grains of chlorate of potash. This may also be conveniently used in the 
form of spray, with the steam atomizer, or thrown up the nostrils with the 
hand atomizer. 

In pseudo-membranous coryza the main treatment must be directed to 
the accompanying laryngitis, if, as is usual, the latter affection is present, 
since the coryza is much less dangerous than the other inflammation. 
Still, if it cause any obstruction to the respiration and increase the suffer- 
ing of the patient, it requires attention. The same mixtures which have 
been recommended in our remarks relating to the local treatment of diph- 
theritic croup are also applicable in the treatment of pseudo-membranous 
coryza. The spray from the steam atomizer inhaled through the nostrils 
exerts the same solvent and curative effect upon the exudative inflamma- 
tion of the nasal surface, as it does upon that of the larynx. The mixtures 
alluded to, which are recommended on page 260, may also be thrown into 
the nostrils with a small syringe, the head of the child being held back, 
and eyes covered ; but they should be used with two or three times their 
quantity of warm water, for solutions injected into the nostrils should 
always be warm, and so weak as to cause little or no smarting. Chronic 
coryza, dependent on a dyscrasia, is best treated by tonic and alterative 
remedies. The various ferruginous preparations, as wine of iron, tincture 



SIMPLE LARYNGITIS. 495 

of the chloride of iron, iron lozenges, may be advantageously employed, 
or the vegetable tonics. If there are pallor, softness of flesh, and espe- 
cially glandular swellings, indicating a scrofulous state of system, the 
syrup of the iodide of iron is useful, with or without cod-liver oil. The 
diet should be nutritious, and the hygienic measures such as invigorate the 
general health. Injections into the nostrils of a solution of alum, five 
grains to the ounce, of nitrate of silver, three to five grains to the ounce, 
or of one of the other -mineral astringents, are sometimes useful in connec- 
tion with constitutional measures. A good formula in chronic coryza, 
for application to parts which can be reached by a camel's-hair pencil, is 
the following : — 

R,. Ung. hydrarg. nitratis, 5U ; 
Ung. zinci oxid., ^ij. Misce. 

At the Outdoor Department of Belle vue, this ointment has proved 
more effectual in this disease than any other local remedy. It should be 
applied at least three or four times daily, as far within the nostrils as 
possible. Recently it has been modified by the substitution of Squibb's 
five per cent, solution of oleate of mercury in place of the citrine oint- 
ment. The zinc ointment is softer and therefore applied more readily 
with the camel's-hair pencil, if made up with vaseline. 

Meigs and Pepper recommend the following ointment in chronic coryza, 
to be applied at night, after the use of injections through the day: — 

R. Unguenti hydrargyri nitratis, gss ; 
Extracti belladonnas, gr. x ; 
Axungiae, £ss. Misce. 

In a case now under observation, of severe ulcerative coryza, due to in- 
herited syphilitic taint, the application once daily of a few drops of the 
oleate of mercury, has within two weeks produced marked amelioration 
of the inflamed surface. 



CHAPTER II. 

CATARRHAL LARYNGITIS. 

Acute catarrhal laryngitis occurs at all ages, but it is so common in 
infancy and childhood, that it is proper to treat of it in a work relating to 
the diseases of these periods. Like other inflammatory affections of the 
air-passages, it is most common in the cold months, or when the weather 
is changeable. Its usual cause is, therefore, exposure to cold. Protracted 
and violent crying, and the inhalation of acrid vapors are occasional 
causes. Catarrhal, or as it is sometimes designated simple laryngitis, 
also occurs in connection with certain constitutional diseases, among which 



496 CATARRHAL LARYNGITIS. 

may be mentioned, measles, scarlatina, and variola. Laryngitis is also a 
common accompaniment of bronchitis, and not infrequently of pneumonitis? 
though its symptoms are apt to be obscured by those of the graver disease. 
It often likewise accompanies pharyngitis, due to extension of the inflam- 
mation. 

Symptoms Catarrhal laryngitis produced by the impression of cold, is 

commonly preceded and accompanied by coryza. The initial symptom 
is chilliness, followed by sneezing, and the discharge of thin mucus from 
the nostrils in consequence of irritation of the Schneiderian membrane. 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries, or, if old enough, when it attempts to 
speak. There is often in severe cases complete loss of voice, so that speech 
above a whisper is impossible. I have noticed this most frequently in the 
laryngitis which accompanies measles. A cough occurs which is at 
first dry and husky but becomes loose in the course of a few days. Ex- 
pectoration is scanty, unless the inflammation has extended to the trachea 
and bronchial tubes. 

This disease is often accompanied by soreness of the throat, noticed in 
the act of coughing or when the larynx is pressed with the finger. In 
laryngeal catarrh, when uncomplicated, the respiration remains nearly 
natural and the pulse is but little accelerated. In mild cases the nature 
of the disease is often not apparent as long as the child remains quiet, in 
consequence of the absence of symptoms, but the character of the voice, 
when it cries or speaks, or of the cough, reveals at once the nature of the 
affection. 

Acute laryngeal catarrh subsides in from one to two weeks. Occasion- 
ally it lasts three or four weeks before the symptoms entirely disappear. 
Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its 
anatomical characters are similar to those in other chronic inflammations 
affecting mucous surfaces, namely, thickening and more or less infiltra- 
tion of the mucous membrane, increased proliferation and exfoliation of 
the epithelial cells, and increased functional activity of the muciparous 
follicles. 

In the adult, chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child syphilitic and tubercular 
laryngitis is more rare, but the latter sometimes occurs in connection with 
pulmonary or bronchial tuberculosis. Such patients are emaciated, and have 
the ordinary symptoms of the tubercular disease. Chronic laryngitis also 
occurs in young children, usually infants, as one of the manifestations of the 
strumous diathesis. I have records of several such cases, mostly nursing 
infants. Some of these patients had mild bronchitis, but it was obviously 
subordinate to the laryngitis. Their respiration was noisy and harsh, con- 
tinuing of this character for several weeks and even months. The cough 



ANATOMICAL CHARACTERS. 497 

was also harsh and loud, conveying the idea of thickening and relaxation 
of the mucous membrane covering the vocal cords. Their respiration was 
not notably accelerated, and the blood was apparently fully oxygenated, 
though the friends were often alarmed by the noisy breathing and cough. 

In this form of chronic laryngitis there is little expectoration, the fever 
is slight or absent, the appetite remains unimpaired, and the general con- 
dition of the child is good. There are from time to time exacerbations, 
and occasionally improvement is such as to encourage the hope of speedy 
cure, but in the cases which I have seen there has not been complete inter- 
mission in the disease till the final recovery. Those patients whom I have 
been able to follow through the disease have recovered in from three or 
four months to one year. 

Chronic laryngitis is to be distinguished from frequent attacks of acute 
laryngitis, which are due to fresh exposures, and also from the laryngitis 
which is associated with bronchial phthisis. It is to be distinguished from 
protracted acute laryngitis, which sometimes does not entirely subside in 
less than a month or six weeks, by its longer duration, the greater thicken- 
ing of the inflamed membrane, and more noisy respiration. Often chronic 
laryngitis results from the acute disease, the inflammation being perpetu- 
ated by the struma or dyscrasia of the patients. 

Anatomical Characters In acute catarrhal laryngitis the mucous 

membrane of the larynx presents the usual appearance of mucous sur- 
faces when inflamed, namely, redness and thickening. It is also somewhat 
softened. Ulcerations rarely, perhaps never, occur in primary acute laryn- 
gitis. When present in chronic laryngitis, the ulcers are small and situ- 
ated upon or near the vocal cords. Tubercular and syphilitic ulcers of 
the larynx are much more rare in children than in adults. The inflamma- 
tion in simple acute laryngitis usually extends over the whole surface of 
the larynx, and also to the upper part of the trachea. It may be pretty 
uniform, or more intense in one place than another, and, like other mucous 
inflammations, it is accompanied by more or less rapid proliferation and 
exfoliation of epithelial cells. In most cases of simple laryngitis, whether 
acute or chronic, the inflammation extends to the pharynx, producing 
redness and thickening, though generally moderate, of the mucous mem- 
brane which covers it. Examination of the fauces therefore aids in diaar- 
nosis. 

In the adult oedema glottidis occasionally results from laryngitis. In 
the child there is little danger that this will occur, in consequence of the 
anatomical character of the larynx. In early life there is but little sub- 
mucous connective tissue in the larynx, and therefore less submucous 
infiltration or effusion during the inflammation. The structural changes 
occurring in catarrhal laryngitis of infancy and childhood relate almost 
exclusively to the mucous membrane. 
32 



498 SPASMODIC LARYNGITIS. 

Treatment — Primary and uncomplicated catarrhal laryngitis requires 
little treatment. Most cases would do well by the employment of suitable 
hygienic measures, without medicines. Benefit is, however, derived from 
the use of demulcent drinks and an occasional laxative. A mixture of 
paregoric and syrup of ipecacuanha, or a small Dover's powder, will re- 
lieve the cough if it is troublesome. For restlessness, a warm mustard 
foot-bath is useful. Inhalation of the spray of glycerine and water from 
the atomizer, or of steam, plain or medicated, is also useful. Mildly stimu- 
lating embrocation, as by camphorated oil with or without a little turpen- 
tine, also aids. It should be rubbed several times daily over the throat, or 
a strip of flannel soaked w r ith it may be applied around the neck. Chronic 
laryngitis dependent on syphilis or tuberculosis requires the constitutional 
treatment Which is appropriate for that disease. Measures not specific 
have little effect upon this form of inflammation. The chronic laryngitis 
which I have described as occurring chiefly in infancy, and which appears 
to be of a strumous character, is apt to be obstinate. The patient should 
be warmly clothed, and constant care should be taken that there be no 
exposure which would endanger taking cold, as this would produce 
an exacerbation of the disease, and tend to counteract what had been 
gained by remedial measures. This form of chronic laryngitis is most 
satisfactorily treated by the application of tincture of iodine upon the 
neck, directly over the larynx, and the internal use of cod-liver oil and 
the syrup of the iodide of iron. Little benefit results in this inflamma- 
tion from the usual expectorant remedies, as squills or senega. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in contradis- 
tinction to true or pseudo-membranous croup, and, by some of the conti- 
nental writers, stridulous angina or stridulous laryngitis. It should not 
be confounded with spasm of the glottis, which is a form of internal con- 
vulsions, and is not inflammatory. It occurs ordinarily between the ages 
of two and five years. It is commonly a sporadic affection, but Rilliet 
and Barthez state that " it is incontestable that it may prevail epidemi- 
cally." They express this opinion, not from their own observations, but 
chiefly from those of Jurine, made in the commencement of the present 
century. 

Causes Children in some families are more liable to false croup than 

in others, so that an hereditary tendency to it must be admitted. The 
exciting cause in most cases is exposure to cold. False croup is not un- 
common in the commencement of measles. Narrowness of the rima 
glottidis, and an excitable state of the nervous system both of which are 
common in early childhood, are predisposing causes. 



SYMPTOMS. 499 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or 
two by a slight cough and fever, by symptoms of mild nasal catarrh, 
such as all children are liable to on taking cold. In exceptional cases 
these symptoms are absent and the disease begins abruptly. Singularly, 
it commences in most patients at night, after the first sleep, between ten 
and twelve o'clock. The sleep is usually quiet and natural, but the child 
awakens with a loud, barking cough. There is great dyspnoea, and the 
respiration is harsh or whistling, on account of the narrowing of the chink 
of the glottis from the swelling and tension of the vocal cords. The face 
is flushed and indicative of suffering. The child cries, moves from one 
position to another, wishes to be held or carried, seeking in vain for re- 
lief. The skin is hot, pulse accelerated, the voice hoarse or even whisper- 
ing. After a variable period, usually from half an hour to two or three — 
not more than half an hour with proper treatment — these symptoms abate. 
The patient is then somewhat exhausted, and falls asleep. The face is 
less flushed or even pallid, the heat abates, and the pulse is less acceler- 
ated. The cough, though less frequent, remains for a time barking or 
sonorous, and the respiration, though greatly relieved, is not at once en- 
tirely natural, but it gradually becomes so. Often there is no return of 
the spasmodic respiration and cough, but sometimes the attack is repeated 
once or more, especially during the subsequent nights. The symptoms 
vary greatly in intensity in different patients. 

As the attack declines, the disease, losing its spasmodic character, be- 
comes a simple inflammation. In some patients there is immediate return 
to perfect health, but oftener the inflammation extends not only into the 
trachea, but also into the larger bronchial tubes, and there remains a 
tracheo-bronchitis which gradually declines. 

The termination is not always so favorable. Spasmodic laryngitis is, 
in exceptional instances, the precursor of other serious affections, which 
may prove fatal. It has been stated that measles often begins with spas- 
modic laryngitis. Bronchitis becoming capillary, may occur in connection 
with it, as may also pneumonia, and by either of these severe inflamma- 
tions the prognosis may be rendered doubtful. There are a few cases on 
record in which it is believed that spasmodic laryngitis w T as of itself fatal. 
In some of these cases the dyspnoea was extreme and persistent, and was 
the cause of death. In a case reported by Rogery, on the other hand, the 
respiration became easy before death, and the pulse more and more fre- 
quent and feeble. Death apparently occurred from exhaustion. It is not 
improbable that, had careful post-mortem examinations been made in those 
cases of spasmodic laryngitis which have ended fatally, other lesions would 
have been discovered besides those located in the larynx, perhaps tracheo- 
bronchitis, with an accumulation of mucus in the larynx, producing suffo- 
cation, or perhaps in some cases congestion of the brain or lungs and serous 
effusion. 



500 SPASMODIC LARYNGITIS. 

Anatomical Character — Pathology The opportunity does not 

often occur of determining the anatomical characters of spasmodic laryn- 
gitis. I have witnessed but one post-mortem examination. A little girl, 
nine years old, was taken on Friday night with cough and dyspnoea, indi- 
cating a pretty severe attack. The mother, acting through the advice of 
a friend, gave kerosene oil to her in considerable quantity. This was suc- 
ceeded by obstinate vomiting and purging, which continued during Satur- 
day and Sunday, and terminated fatally on Monday. At the autopsy we 
found uniform and "intense injection throughout the whole extent of the 
larynx and trachea and in the bronchial tubes, but there was no pseudo- 
membrane on the inflamed surface, and but little mucus and pus. The 
solitary follicles of the intestines and Peyer's patches were tumefied, and 
the gastro-intestinal surface was injected in places. The cause of death 
was obviously the diarrhoea, apparently of an inflammatory character, and 
probably produced by the kerosene oil. The condition of the mucous 
membrane of the larynx was that which is ordinarily present in spasmodic 
laryngitis, though in some cases in which post-mortem examinations have 
been made the evidences of laryngeal inflammation were slight. Guersant 
relates a case in which the surface of the larynx seemed to be nearly in 
its normal state. Death in cases of slight laryngitis is due to causes which 
are independent of the larynx. In Guersant's case there was tuberculosis. 

There is, as has already been intimated, another and an important 
element besides the inflammation in the pathology of spasmodic laryn- 
gitis — an element producing those phenomena which render it a disease 
distinct from simple laryngitis. I refer to spasm of the laryngeal muscles. 
This element pertains to the nervous system, so that spasmodic laryngitis 
is allied both to the neuroses and to the inflammations. 

Diagnosis The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, 
usually make this mistake in forming their opinion of the case before the 
physician arrives; and there can be no doubt that many of the cases which 
physicians have published in medical journals as true croup were ex- 
amples of this affection. The points of differential diagnosis are the fol- 
lowing : True croup begins with symptoms which at first are slight, so as 
scarcely to arrest attention, but which gradually increase in intensity. The 
cough becomes more harsh, and the respiration more difficult, by degrees. 
This increase in the gravity of the symptoms occurs by day as well as by 
night. On the other hand, false croup, though preceded by symptoms of 
nasal catarrh, commences abruptly. The symptoms have from the first 
their maximum intensity, and the time at which it commences is the night. 
Again, the cough in spasmodic laryngitis possesses a loud, sonorous char- 
acter; while in true croup it is harsh or rough, from the presence of the 
membrane, and having, therefore, less fulness. The voice in spasmodic 
laryngitis may be hoarse, but it is not lost, or is lost only for a short time. 



PROGNOSIS — TREATMENT. 501 

It afterwards becomes natural, or is slightly hoarse. On the other hand, 
in true croup, the voice, from being natural at first, is gradually ex- 
tinguished. In fatal cases it soon becomes whispering, and continues such 
till the close of life; in those that recover, the voice remains hoarse for 
several days. These differences are important, and, if fully appreciated, 
are in most instances sufficient to establish the diagnosis. Besides, in a 
large proportion of cases of true croup, portions of the pseudo-membrane 
may be discovered on inspecting the fauces, and the faucial surface is 
deeply injected, while in spasmodic laryngitis there is, with rare excep- 
tions, no false membrane upon the surface of the fauces, and but a moder- 
ate amount of congestion. 

Laryngismus stridulus, or internal convulsions, must not be confounded 
with this disease. It is not inflammatory, but purely spasmodic, suddenly 
commencing and abating — identical, it is believed, in character, with 
tonic convulsions of the external muscles, but affecting the internal 
muscles of respiration. This disease has already been fully described. 

Prognosis Little need be added, as regards the prognosis, to what 

has already been stated. While a favorable opinion in reference to the 
result may ordinarily be expressed, the physician should not forget the 
fact that death may occur. Symptoms indicating an unfavorable termi- 
nation are : great and continued dyspnoea, not diminished by the proper 
remedial measures ; stridulous expiration as well as inspiration ; lividity 
of the prolabia and fingers ; pallor and coldness of surface ; pulse progres- 
sively more frequent and feeble. Convulsions and coma may also occur 
near the close of life. 

Treatment. — The indications of treatment are twofold: first, to relieve 
the spasmodic action of the laryngeal muscles ; secondly, to cure the laryn- 
gitis. To meet the first indication, a warm bath of the temperature of 
about 100° should be employed as soon as possible after the commence- 
ment of the attack. The patient should be kept in it ten or fifteen minutes, 
in order to obtain its full relaxing effect. In mild cases a warm foot-bath 
may be sufficient. A second means is the use of an emetic, which should 
be simultaneous with the bath. To children under the age of three years, 
syrup of ipecacuanha should be given, in doses of one teaspoonful, repeated 
in twenty minutes, till vomiting occurs; or alum and syrup of ipecac- 
uanha, two drachms of the former to one ounce of the latter, may be given 
in the same dose. The alum and the syrup produce more prompt emesis 
than the syrup alone. Children over the age of three years, unless of 
feeble constitutions, are best treated by the compound syrup of squills in 
teaspoonful doses, or a mixture of this with syrup of ipecauanha. It is 
not often necessary to give more than three or four doses, and sometimes 
one or two are sufficient to produce vomiting. 

In most cases, by the use of the warm bath and the emetic, the symp- 
toms are rendered milder, and convalescence soon commences. 



502 SPASMODIC LARYNGITIS. 

In the American Journal of the Medical Sciences, April, 1867, Dr. R. R. 
Livingstone reports a case of laryngitis treated by Squibb's ether. It is 
stated that portions of pseudo-membrane, from one-eighth to three-fourths 
of an inch in length, were expectorated; but the symptoms certainly indi- 
cated a spasmodic element as decided as in spasmodic croup, and the bene- 
fit from the ether was apparently due to the relaxation of the laryngeal 
muscles which it produced. The treatment of the patient, who was two 
years old, was commenced by the administration by the mouth of half a 
teaspoonful of the ether, and followed by its inhalation. "In precisely 
eight minutes from the time the patient commenced the inhalation, the 
abnormal muscular exertion ceased ; a general relaxation took place ; the 
pulse (which had numbered 150) fell to 100." Ether, judiciously em- 
ployed, will probably prove to be a useful remedial agent in spasmodic 
forms of laryngitis, whether or not it has any effect on pseudo-membranous 
formations. A large majority of cases, however, recover speedily without 
its employment, or by the other measures recommended. 

Attention should always be given to the state of the bowels in spasmodic 
laryngitis. If they are not well open, a purgative should be administered. 
For those that are robust, and with considerable febrile movement, the 
saline cathartics are ordinarily preferable, as Rochelle salts, or a purgative 
dose of calomel may be administered. The cathartic should not be pre- 
scribed till the nausea from the emetic has subsided. By its derivative 
effect, it tends to diminish the laryngitis, and, in severe cases, it may ob- 
viate the need of depletion by leeches. 

Inhalation of the vapor of hot water, and the application of a sinapism 
over the neck and upper part of the sternum, followed by an emollient 
poultice, are useful adjuvants to the treatment. 

The most convenient and effectual way of employing vapor is, however, 
by the atomizer, and as the chief danger is that the inflammation may be- 
come pseudo-membranous, I am in the habit of using in the atomizer 
lime-water with one-fifth or one-sixth part of glycerine. 

When the spasmodic element in the disease is relieved, the case becomes 
one of simple laryngitis, and the general plan of treatment recommended 
for that disease is proper for this. Small doses of ipecacuanha, or of one 
of the antimonial preparations, as the compound syrup of squills, not suffi- 
cient to cause nausea, should now be given at regular intervals. I have 
sometimes added to the expectorant one drop of the tincture of aconite 
root for robust children over the age of three or four years, having a full 
and rapid pulse, flushed face, and other evidences of active febrile move- 
ment. Its effect should be watched, and it should be discontinued when 
its sedative influence on the circulation begins to be apparent. It should 
not be given in the spasmodic laryngitis which occurs in the commence- 
ment of measles. 

If, however, there is not a speedy termination of the disease by recovery, 



TREATMENT. 503 

or, more rarely, by death, there is nearly always tracheo-bronchitis, or a 
more serious affection, coexisting with the laryngitis, or following it; there- 
fore, depressing measures should not be long continued. Expectorants of 
a stimulating character, as carbonate of ammonia, or syrup of senega, are 
required in the course of a few days, and in young and feeble children 
they should be given at an early period. 

The mode of treatment recommended above is appropriate for that large 
class in whom the inflammatory element predominates. In a smaller 
number of cases the nervous element predominates over the inflammatory, 
and the treatment should be in some respects different. Such children 
are usually pallid and of spare habit, having, indeed, the nervous tempera- 
ment. They are liable to attacks of this disease, though generally of a 
mild form, on slight exposure to cold, and with a very moderate amount 
of inflammation. The treatment in these cases should be directed more 
to the nervous system. My plan has been, in the treatment of such patients, 
after perhaps the use of a mild emetic, to give quinine, one grain three or 
four times daily, to a child from three to five years old, prescribing at the 
same time a simple expectorant, as syrup of squills, and a mildly irritating 
application to the throat. The symptoms in these cases are not severe, 
and active measures are not required, though the peculiar cough continues 
longer than in the more inflammatory forms of the disease. 

The patient with spasmodic laryngitis should be kept in a warm room 
during the paroxysms, and should inhale an atmosphere loaded with 
moisture. 

Trousseau recommends a mode of treatment of spasmodic laryngitis 
which was first suggested by Graves, of Dublin. It consists in the appli- 
cation underneath the chin, so as to cover the larynx, of a sponge soaked 
in water as hot as can be borne ; in ten or fifteen minutes it is repeated. 
This reddens the skin, producing revulsion from the larynx. The hoarse- 
ness, dyspnoea, and cough diminish with this treatment, and some recover 
without other measures. 

Guersant and others speak of the importance of prophylactic manage- 
ment of children who are liable to this disease. Attention should be given 
to the dress, so that there may be sufficient protection from changes of 
temperature, and there should be an equable temperature of the apartments 
in which they reside. Children of a decidedly nervous temperament, in 
whom the slightest laryngitis is apt to be spasmodic, require additional 
prophylactic measures. They are pallid, and in a more or less cachectic 
state. Such children are benefited by chalybeate and vegetable tonics, 
and by exercise in suitable weather in the open air. 



504 PSEUDO-MEMBRANOUS LARYNGITIS. 



CHAPTER III. 

PSEUDO-MEMBRANOUS LARYNGITIS. 

The term pseudo-membranous laryngitis, or true croup, is applied to a 
common and fatal disease, the essential anatomical character of which is 
inflammation of the mucous membrane of the larynx, with the formation 
upon its surface of a pseudo-membrane. It occurs most frequently between 
the ages of two and seven years. It is rare in adult life, and also under 
the age of six months. 

Causes — There is greater liability to this disease in some children than 
in others, and occasionally the predisposition to it appears to be inherited. 
The common exciting cause is exposure to cold. Those children, especially, 
are liable to croup, who live in heated apartments, and are taken into the 
open air without proper covering, and those who a part of the time are 
warmly and a part of the time thinly clothed, especially as regards the 
covering of the neck. This disease is common among the poor of New 
York, who live in close rooms, overheated through the day and cool at 
night. Another less common cause is the inhalation of irritating vapors, 
or swallowing irritating or corrosive liquids. I have known a child to die 
from swallowing acetic acid, and another from scalding water, both hav- 
ing the dyspnoea and cough of true croup. 

This disease is ordinarily primary, but occasionally it is secondary. The 
secondary form is not unusual in the declining period of measles, and it is 
an occasional complication of scarlet fever. Croup is most common in the 
winter months, and in times of changeable weather. It is said, also, that 
it sometimes occurs as an epidemic, but it is a question whether the sup- 
posed epidemics may not have been diphtheritic. 

Anatomical Characters The inflammatory action in this malady 

affects not only the mucous membrane, but, in a certain proportion of 
cases, extends to the submucous connective tissue, causing infiltration or 
oedema. The mucous membrane itself undergoes similar alteration to that 
in simple or spasmodic laryngitis, consisting of hyperemia and thickening, 
proliferation, and rapid desquamation of its epithelial cells, and an abun- 
dant production of muco-pus. Sometimes the redness is found only in 
patches at the autopsy ; in other cases it extends over the whole surface of 
the larynx. Exceptionally the redness has disappeared, so that the laryngeal 
mucous membrane, though thickened and softened, presents nearly its 
normal color. In all except the mildest cases the inflammation extends 



ANATOMICAL CHARACTEES. 505. 

further than the larynx, involving not only the surface of the pharynx, 
but also in greater or less degree that of the trachea and bronchial tubes. 

The distinguishing feature as regards the anatomical character of this 
disease remains to be noticed, namely, the false membrane which covers 
the laryngeal and often contiguous surfaces. It has long been supposed 
that this consists of fibrin, which, exuding in its liquid state from the 
submucous vessels, becomes fibrillated when exposed to the air, its inter- 
stices being filled with a greater or less amount of pus, epithelial cells, and 
amorphous matter. At a recent date "Wagner surprised pathologists by 
the statements that these pseudo-membranes contain no fibrin, but that 
they consist of epithelial cells, which, undergoing some form of degenera- 
tion as they are pushed forward from the mucous surface, enlarge so as 
to appear under the microscope as irregular blocks interlacing with eacli 
other. By employing the picro-carminate of ammonia, or a weak ararao- 
niacal solution of carmine, Weber and other microscopists have been able 
to trace the boundaries of these irregular and interlacing blocks, Avhich 
have prolongations like the shape of a stag's horns, and they have ob- 
served the intermediate forms of transition between these and the normal 
epithelial cells. 

But some of the highest authorities in pathological histology, as Rind- 
fleisch, state that they find fibrin in the pseudo-membrane, in addition to 
the enlarged and degenerated epithelial cells of which it is chiefly com- 
posed. Rindfleisch says : u The pseudo-membrane is of a peculiarly strati- 
fied structure, since upon a layer of cells at tolerably equal distances there 
always follows a layer of fibrin, and this sequence is repeated from one to 
ten times, according to the thickness of the membrane." (Patholog. Histol., 
translated, page 351.) As lending support to the views that the pseudo- 
membrane does contain fibrin, the fact may be stated, that while in the 
ordinary pneumonia of young children there is no fibrinous exudation in 
the air-cells, this exudation does occur, at least in a certain proportion of 
cases, in pneumonia occurring as a complication of croup. Thus, recently, 
in this city, in a pneumonic lung, from a case of fatal croup, occurring at 
the age of about two years, Prof. Francis Delafield found fibrin in the ex- 
udation of the air-cells. The exact nature of the degeneration which the 
epithelial cells undergo is unknown. Their appearance is so altered by 
protoplasmic change and infiltration, that they can be recognized as 
altered epithelial cells only by chemical tests. MM. Cornil and Ranvier 
state : " We have verified the correctness of the description given by 
Wagner; we have separated and colored the cells by means of the picro- 
carminate of ammonia, and, in consequence of the facility which they 
present of fixing the carmine, we conclude that they are not filled with 
fibrin, but rather by a matter resembling mucin. These exudats of true 
croup are pressed forward and detached in proportion as the globules of 
pus or new epithelial cells are produced underneath them." 



506 PSEUDO-MEMBRANOUS LARYNGITIS. 

In Yirchow's Archiv., Band, lxx, 1877, Dr. Carl Weigert relates very 
interesting experiments in which he produced pseudo-membranous croup 
upon the laryngo-traehial surface of the rabbit; by applying to it a weak 
ammoniacal solution. After two days the animal was killed, and the exu- 
dation was carefully examined. The mucous membrane underneath the 
exudation was found hyperaemic, and denuded of epithelium. Weigert, 
indeed, concluded from his observations, that the croupous membrane does 
not form, unless the epithelial layer is first destroyed, a point, in reference 
to which some of the New York microscopists would take issue. The 
relation of the pseudo-membrane to the mucous surface was simply that of 
contact. The microscopic examination of the adventitious layer was in- 
teresting. Its lowest part contained ill-defined (informes) elements, some 
of which preserved a resemblance to the epithelial cells. By the addition 
of strong acetic acid, these elements swelled, took the form of epithelial 
cells and exhibited nuclei. Free nuclei were found in the interspaces, 
more resembling pus cells or white blood corpuscles than the nuclei of 
epithelial cells. Therefore Dr. TV. concludes that the undermost part of 
the croupous layer consists mainly of epithelial debris. Secondly, imme- 
diately above this he found a different layer consisting of a network of 
delicate fibres in the meshes of which were free nuclei. This network 
evidently consisted of fibrin, as it gave the reactions of this substance. 
Thirdly, penetrating the upper part of the fibrinous network and overlying 
it was a layer of mucus containing large cells with large nuclei, and 
grains of black pigment. From all these examinations which have been 
made by competent microscopists, we must conclude that the croupous 
exudation consists largely of altered epithelial cells, and that it also con- 
tains a network of fibrin. 

The pseudo-membrane varies greatly in amount in different cases. It 
may occur only in points or small patches, which are generally found in 
the vicinity of the vocal cords, while in other cases it extends an almost 
continuous membrane from the epiglottis into the bronchial tubes, and 
there is every grade between these two extremes. It fills the orifices 
of the muciparous follicles, and the minute depressions upon the mucous 
surface, being closely adherent, so as not to be detached by efforts of cough- 
ing or vomiting, except in small portions. 

As the inflammation commonly extends beyond the larynx, so the 
pseudo-membrane, in a large proportion of cases, is formed not only upon 
the laryngeal, but also upon contiguous surfaces. In thirty-three cases of 
true croup, comprised in the statistics of Dr. Ware, of Boston, pseudo- 
membranous pharyngitis was also present in all but one ; and in nineteen 
cases observed by Dr. Meigs, of Philadelphia, in all but three. The 
formation of a pseudo-membrane in the trachea in connection with that in 
the larynx is also common, and is not infrequent in the bronchial tubes. 
M. Guersant has, so far as I am aware, collected the largest number of 



SYMPTOMS. 507 

records relating to the extent of the pseuclo-membrane in true croup. In 
an ao-oregate of 120 cases it was confined to the larynx and trachea in 78, 
or about two-thirds, while in the remainder, namely, 42, it extended into 
the bronchial tubes. 

In those whose systems are robust, the false membrane is usually firmer 
than in those whose systems are reduced. In a state of decided cachexia 
it is sometimes friable and easily detached. If the case continue from 
four to six days, it begins to soften from commencing decomposition, the 
minute fibres which attach it to the mucous membrane give way, and, in 
favorable cases, by the effort of coughing or vomiting, it is thrown off. 
Separation is aided by muco-pus, which collects underneath. In fatal 
cases the false membrane, if detached by the efforts of the child, may be 
reproduced, so that in twelve to eighteen hours the dyspnoea returns. 
Pneumonia not infrequently complicates croup. In extreme cases, in 
which inspiration is difficult in consequence of the obstruction, the lungs 
are only partially inflated, and imperfect decarbonization of the blood and 
sometimes collapse of certain pulmonary lobules are the result. Occasion- 
ally there is that degree of thickening of the mucous membrane, and sub- 
mucous infiltration, that the dyspnoea and danger occur more from these 
than from the presence of the pseudo-membrane. 

Symptoms. — In some cases, pseudo-membranous, like catarrhal laryn- 
gitis, is preceded by coryza and pharyngitis, while in others laryngitis is 
present from the first. The commencement of croup is indicated not only 
by fever, diminished appetite, thirst, and such symptoms as accompany 
all acute inflammations, but by certain other symptoms which serve to 
distinguish this from all other diseases, except diphtheritic croup. 

The cough is one of the earliest symptoms which distinguish true croup 
from other laryngeal inflammations. It is hoarse or harsh ; its character 
may be expressed by the term dry or suppressed. It differs from the cough 
of spasmodic laryngitis, which is less hoarse and more sonorous. It is 
much more frequent in some cases than in others ; in many patients, 
towards the close of life, it nearly or quite ceases. Hoarseness of the 
voice is also one of the first and most constant symptoms, and it continues 
throughout. Towards the close of life the voice is usually lost, and the 
child expresses its thoughts in an indistinct whisper. 

The amount of expectoration varies considerably in different patients, 
according to the presence or absence of bronchial inflammation. If the 
inflammation extends no lower than the upper part of the trachea, the 
sputum is scanty during the whole course of the disease. In ordinary 
cases it is scanty at first, then more abundant, and again more scanty if 
the case is fatal. The scantiness of the sputum towards the close of life 
is due not entirely to exhaustion of the patient, but in part to obstruction 
in the larynx above the mucus and pus. By vomiting a much larger 
quantity is expectorated than by the cough. Frequently small portions 



508 PSEUDO-MEMBRANOUS LARYNGITIS. 

of pseudo-membrane are expectorated with the mucus and pus, and occa- 
sionally also larger masses, complete moulds, indeed, of the larynx, trachea, 
or even of the bronchial tubes. 

The respiration is accelerated, but not so much as in pneumonia or 
capillary bronchitis. In the advanced stage it commonly becomes slower 
than at first. As the obstruction in the larynx increases, the respiration 
assumes more and more the character which has been designated abdom- 
inal ; the infra-mammary region is depressed in each inspiratory act, while 
the larynx approaches the sternum, and the aire nasi are dilated. Patients 
sometimes have painful attacks of dyspnoea, due to detachment of an edge 
of the pseudo-membrane, and its doubling upon itself. In the paroxysm, 
the sufferer throws himself from side to side in the bed, or reaches his arms 
to his mother or nurse for relief; his eyes are wild, features anxious, and, 
in severe paroxysms, fingers and prolabia livid. In the interval there is 
comparative quietude, though the respiration is constantly embarrassed. 

The frequency of the pulse varies according to the extent of the inflam- 
mation and the stage of the disease. In the commencement of primary 
croup it ordinarily varies from about one hundred and ten to one hundred 
and twenty beats per minute. In the course of the disease it becomes 
more frequent, and towards the close of life feeble. 

Now and then a patient presents a remission in symptoms, due to expec- 
toration of membranous shreds and muco-pus, and the friends may think 
that the danger is passed. Unfortunately the lull in symptoms is in most 
cases deceitful, as the cause of the dyspnoea is rapidly reproduced. I once 
attended a case in which there had been such dyspnoea that an unfavor- 
able prognosis was given. An almost complete intermission, however, 
occurred in the symptoms, with the exception of the febrile movement, so 
that a physician who visited the patient at this time diagnosticated an 
essential fever. Within a few hours, the obstruction being reproduced, 
the symptoms returned with greater violence than ever, and the child 
died. So complete an intermission seldom occurs in a fatal case ; and in 
most patients, during the time of temporary improvement, there is still 
such dyspnoea, with the characteristic cough, that the nature of the dis- 
ease is apparent. 

If the stethoscope is applied over the larynx in true croup, the loud 
expiratory as well as inspiratory sound is heard as the air passes by the 
obstruction. This sound is often transmitted to every part of the chest, 
so as to obscure the rales which may be produced there. Auscultation 
over the chest reveals either the vesicular murmur, perhaps somewhat 
diminished in intensity, or more frequently the sonorous and afterwards 
moist rales due to coexisting bronchitis. In a limited number of cases, 
dulness on percussion is observed at some part of the chest, with bronchial 
respiration, indicating pneumonia. Recovery from croup is in most 
patients gradual; the voice becomes less hoarse, the cough looser, and the 



PATHOLOGICAL CHARACTERS. 509 

dyspnoea ceases by degrees. The structural changes which have occurred 
in the mucous membrane of the larynx do not disappear till several days 
after the last pseudo-membrane is detached. 

Fatal cases may terminate in two or three days, but their ordinary 
duration is from five to fourteen days. Death may result directly from 
the thickness and firmness of the pseudo-membrane, which obstructs the 
entrance of air. Sudden death in a paroxysm of dyspnoea may occur from 
the detachment of one end of the pseudo-membrane, and its folding upon 
itself. In many patients, death is not due so much to obstruction to the 
entrance of air from the presence of the pseudo-membrane, as to the mucus 
and pus which collect in the trachea and bronchial tubes, and which are 
not expectorated on account of the presence of the pseudo-membrane and 
the feeble expiratory efforts of the child. In a case which was examined 
after death in the Nursery and Child's Hospital of this city, the false 
membrane was apparently not sufficient to produce a fatal result, but the 
air-passages below it were nearly filled with muco-purulent matter, which 
obstructed the entrance of air. 

Pathological Characters This disease is then essentially a laryn- 
gitis presenting the lesions of a simple though usually severe mucous in- 
flammation, but with a superadded element, namely, the false membrane. 
The coexistence of catarrhal or pseudo-membranous pharyngitis, tracheitis, 
and bronchitis is also, as we have seen, common. The impediment to 
respiration, which renders croup so dangerous and fatal, is due not only 
to the presence of the false membrane, and to the mucus and pus which 
collect below it, but also to the inflammatory swelling of the mucous mem- 
brane and submucous oedema. In addition, there is a neuropathic element 
which increases the dyspnoea, and which most observers consider a spas- 
modic contraction of the laryngeal muscles induced by the inflammation, 
and hence the easier breathing in sleep, and in the general muscular re- 
laxation, which precedes death. Professor Jacobi (Amer. Jour, of Obstet., 
etc., N. Y., May, 1868), however, holds that the state of these muscles is 
one of paralysis rather than spasmodic contraction. In his opinion, this 
paralysis " is secondary. It depends on the oedematous soaking of the 
posterior crico-arytenoid muscles following the oedema of the mucous mem- 
brane of the crico-arytenoid folds." 

In several fatal cases which I have had an opportunity to examine after 
death, I have found the appearance of the lungs quite uniform. They 
were reduced in volume (semi-collapsed) and more or less congested. 
Certain parts distant from the bronchi, especially the edges and thin por- 
tions, were collapsed completely, and certain lobules also hepatized. I 
have also observed, though in some of the cases my attention was not 
directed to it, distension of the right cavities of the heart, with blood, and 
large thrombi. From the nature of the disease, the blood is less oxyge- 



510 PSEUDO-MEMBRANOUS LARYNGITIS. 

nated, and somewhat darker than in those who die of diseases not involv- 
ing the respiratory apparatus. 

Diagnosis — The diagnosis of true croup is ordinarily easy. It might 
be mistaken for spasmodic laryngitis, but more frequently spasmodic 
laryngitis is mistaken for it. The differences which will aid in differential 
diagnosis are the following : Commencement abrupt and at night in one, 
gradual in the other ; presence in one, absence in the other, of a pseudo- 
membrane upon the surface of the fauces ; fragments of the membrane in 
the sputum in one ; character of the cough ; course of the disease growing 
gradually worse in one, in the other, with few exceptions, rapidly im- 
proving. Trousseau speaks of the liability to error of diagnosis in those 
cases in which spasmodic laryngitis is associated with pseudo-membranous 
pharyngitis. Few physicians hesitate to designate as true croup those 
cases in which there is a croupal cough in connection with false mem- 
brane upon the surface of the fauces, and yet the laryngitis under such 
circumstances may be merely spasmodic. This coexistence of pseudo- 
membranous pharyngeal and of spasmodic laryngeal inflammation is, how- 
ever, probably rare, but its occasional occurrence should be borne in mind. 

True croup is readily distinguished from laryngismus stridulus, or in- 
ternal convulsions. Laryngismus stridulus is a purely nervous affection ; 
it occurs suddenly, causing great dyspnoea, or momentary suspension of 
respiration, without the fever and without the hoarse voice and cough of 
croup. When muscular relaxation occurs, the attack ceases. The dif- 
ference between the two diseases is therefore obvious. 

Prognosis. — The great mortality from true croup is universally known, 
and those physicians who report a large number of favorable cases have 
probably mistaken spasmodic croup for this disease. According to the 
statistics of Dr. Ware, nineteen out of twenty die ; but with the modern 
mode of treatment, begun early, the proportionate number of recoveries is 
probably larger than this estimate. Increase of dyspnoea, cough and voice 
becoming more hoarse, and the pulse more accelerated, indicate a fatal 
form of croup. The occasional temporary improvement due to the expul- 
sion of a portion of the membrane, may lead, as we have seen, to error of 
prognosis. However improvement continuing more than twelve hours is 
evidence of the decline of the malady. The near approach of death is 
shown by lividity with great restlessness, or pallor with somnolence. If 
the patient recover from croup there often remains more or less bronchitis 
or broncho-pneumonia, which requires treatment, and the laryngitis, when 
its pseudo-membranous character is lost, persists for a time, causing more 
or less hoarseness, and increase of temperature. 

Treatment. — The importance of early treatment has been sufficiently 
alluded to, for if croup have continued two or three days, when first recog- 
nized, the chance of recovery is greatly diminished. As the danger is from 
the presence of the adventitious layer, measures should be immediately 



TKEATMENT. 511 

employed to prevent as much as possible its further formation, and remove 
that already formed. 

Emetics, which have been largely employed in times gone by, should, 
as a rule, be employed only in the beginning of croup, and those employed 
which are attended with least depression ; for the strength should be pre- 
served, in order that the cough may continue strong, and sufficient to 
expel any portion of the membrane which may loosen. Moreover it is 
impossible in localities where diphtheria is endemic, to distinguish at the 
bedside membranous from diphtheritic croup, and depressing remedies in 
the latter accelerate, as all know, the fatal result. The emetic causes the 
expulsion of a considerable quantity of mucus, which is found in the mat- 
ter vomited, and it may cause the detachment and expulsion of the softer 
portions of the pseudo-membrane. Syrup or wine of ipecacuanha may be 
given, and repeated after fifteen minutes once or twice, if necessary, pro- 
vided that the previous health of the child has been good, and he is 
robust. The sulphate of copper in two-grain doses given alone, or in sus- 
pension with syrup of ipecacuanha, acts promptly, and with little depres- 
sion. There is, in most cases, more or less relief after the emesis, though 
it may be only temporary. In one case, in my practice, in which there 
were at my first visit dyspnoea, croupy cough, and a pseudo-membrane 
over each tonsil, and in which I had made an unfavorable prognosis, the 
parents, observing the good effects of an emetic containing two grains of 
sulphate of copper and two of pulverized ipecacuanha, repeated the medi- 
cine, contrary to my directions, at intervals of two to four hours till the 
following day, and the patient recovered. Probably, however, in ordinary 
cases the best emetic is the yellow sulphate of mercury prescribed in pow- 
der in two-grain doses. The use of this emetic in croup was prominently 
brought to the notice of the profession in New York City by Prof. For- 
dyce Barker, who prescribes it immediately on being summoned to a case, 
and he states that he has not lost a patient thus treated in several years. 
With or without the emesis other measures are urgently demanded. The 
profession long sought for a remedy, which taken internally, might, by its 
effect on the blood or the inflamed surface, prevent or diminish the mem- 
branous formation, and also for a remedy which, employed topically, 
might liquefy and remove it. Calomel has been much used in times gone 
by for its supposed " anaplastic" action, and more recently chlorate of 
potassa and muriate of ammonia, as in the following formula : — ■ 

R. Potas. chlorat., gi ; 
Ammon. nmriat., ^ss ; 
Syr. simplic, §ss ; 
Aquse, ^ij. Misce. 
Give one teaspoonful every half hour or hourly. 

Since the discontinuance of the calomel treatment this mixture has been 



512 rSEUDO-MEMBRANOUS LARYNGITIS. 

largely used in New York, but it is now being superseded by the atomizer, 
or it is employed along with the atomizer. 

The atmosphere which the child breathes should be constantly loaded 
with moisture, without, however, that degree of heat which would add 
materially to the discomfort of the patient. Moist air coming in contact 
with the inflamed surface promotes expectoration, and renders the cough 
looser. A temperature of 80°, if the atmosphere is loaded with moisture, 
is more readily tolerated than a lower temperature with a dry atmosphere, 
and a temperature as high as 75° to 80° is required, or too much of the 
steam is deposited. 

Of late years a very important instrument has been employed in the 
treatment of acute laryngitis, whether croupous or diphtheritic, and since 
vapor inhaled comes directly in contact with the exudation and the in- 
flamed mucous membrane, the proper use of the atomizer is the most im- 
portant and useful therapeutic measure yet employed to control this dan- 
gerous malady. The steam atomizer is preferable to that employed by 
hand, since a steady and full stream of vapor is produced by means of the 
spirit-lamp, and without the necessity of maintaining an uncomfortably 
high temperature in the room. Lime-water is the most efficient solvent 
of the pesudo-membrane which can be safely employed, and I prefer using 
it with glycerine in the officinal strength, or in double the officinal 
strength, as in the following formula : — 

U. Calcis, §ss; 
Aquae, gviij ; 
Glycerinse, §ij. Misce. 

That nothing may be left undone, I have been in the habit of employ- 
ing each second hour in the atomizer one ounce of the following, which 
occupies not more than fifteen minutes, the lime-water being used con- 
stantly between-times : — 

R. Potas. chlorat., 5*j '■> 
Ammon. nmriat., 3J 5 
Glycerinse, |ij ; 
Aquae, §vj. 

If the croup is not too far advanced, the atomizer thus employed com- 
monly renders the cough looser, the voice clearer, and respiration easier. 
And under its use, more than from any other treatment, we are gratified 
by observing the expectoration of croupous fragments. I am convinced, 
from my observations, that the necessity for tracheotomy might often be 
avoided, and many lives saved, by the early and continued use of this 
simple instrument. The inhalation may be continued for hours without 
wearying the child. A saturated atmosphere, while it may cause swelling 
of the croupous layer, also renders it more friable and more easily expec- 
torated. 



TREATMENT. 513 

In order to reduce the temperature, and at the same time to sustain the 
strength, quinine should be employed. If the temperature is high, it 
should be given in two or three large doses. As an antipyretic it is to be 
greatly preferred to veratrum viride, aconite, or any other agent. If the 
fever is moderate, a smaller dose is preferable, repeated every three or 
four hours. 

It is to be recollected, in the treatment of croup, that the pseudo-mem- 
brane, by commencing decomposition, and by the pus and mucus which 
collect underneath, is more easily detached after a few days, if the patient 
lives, than at first. Therefore the physician should endeavor to sustain 
the vital powers, in order that the cough may have sufficient force to 
separate this substance as soon as its fibres of attachment begin to loosen. 
A patient with croup rarely takes solid food, but he should be allowed 
beef-tea, milk, and farinaceous drinks, at short intervals. If there are 
signs of exhaustion, alcoholic stimulants are proper, and fresh air should 
also be allowed so far as is compatible with the inhalation of steam. 

As regards external treatment of the throat the late Professor Peaslee, 
of this city, in a series of papers on the pathology of croup, published in 
the American Medical Monthly, 1854, says of cold applied externally : 
"We consider this of the greatest value and importance. If cold applica- 
tions are efficacious in all cases of external inflammation, they are scarcely 
less so here, where the inflamed surface is so nearly superficial. Cold 
must, however, be continuously applied to produce the desired effect. 
Applied at intervals, indeed, it rather promotes than retards the inflamma- 
tory process ; since during the intervals the temperature rises above the 
normal standard, in consequence of the reaction of the chill on the surface. 

" Cold water may be constantly dropped from a sponge upon a compress 
laid over the throat of the child ; and the latter should be of only one 
or two thicknesses of linen, that evaporation may go on as rapidly as pos- 
sible." 

In ordinary cases cold applied over the larynx is, in my opinion, pre- 
ferable to poultices or warm applications. Two or three thicknesses of 
muslin soaked with camphorated oil may be applied over the larynx, so 
as to cover the neck in front, and over this a bladder containing pieces of 
ice, or ice surrounded by oil silk, to prevent dripping, be constantly re- 
tained. Ice is, I think, better tolerated when applied in this way than 
where there is no intermediate substance. This mode of applying cold I 
have found more convenient than that recommended by Prof. Peaslee. 
The temperature of the neck may be kept constantly below the normal 
standard by ice thus applied. Cold is especially serviceable if the child is 
robust, with flushed cheeks and full and rapid pulse. In secondary croup, 
or croup occurring in feeble states of system, or presenting a subacute 
character, poultices or fomentations to the neck, with moderate counter 
irritation, sometimes give most relief. 
33 



514 



PS EUDO- MEMBRA NOUS LARYNGITIS. 



Unfortunately, as I have already stated, true croup is, in a large pro- 
portion of cases, a progressive disease. The hoarseness of the cough and 
voice and the dyspnoea gradually increase. The pulse, becoming more 
frequent and feeble, indicates the need of the most nutritious food, as the 
animal broths, and of alcoholic stimulants. The danger is, however, from 
the dyspnoea rather than asthenia. But if other measures fail to give 
relief shall tracheotomy be performed? In the cities where companies 
provide oxygen, in portable apparatus, prepared for inhalation, this agent 
will be found to relieve greatly the dyspnoea, and increase the chances of 
a favorable result. In New York it is often employed, and with much 
relief of suffering. 

The published statistics relating to tracheotomy in croup are to a con- 
siderable extent unsatisfactory, since we are not informed, as regards most 
of them, at what stage of the disease the operation was performed, and 
what were the evidences of a fibrinous exudation. The most valuable 
and reliable statistics bearing upon this subject, so far as I am aware, are 
those published by Prof. Jacobi, of this city, in the American Journal of 
Obstetrics, etc., for May, 1868, and containing the results of the cases 
which were operated on by himself and Drs. Krackowizer and Voss. 
These gentlemen are known to the profession of New York as careful and 
judicious practitioners, not likely to operate when there was probability of 
success by therapeutic measures, and not likely to mistake simple or spas- 
modic laryngitis for true croup. I have tabulated the statistics of their 
operations. But it is evident, at a glance, that these statistics are only 
approximately correct, as showing the proportion of recoveries and deaths, 
after the operation in membranous croup, as certain cases of diphtheritic 
croup have been included. 

Age. 
Under 2 years, 



From 2 to 3 years 


" 3 to 4 " 


" 4 to 5 " 


" 5 to 6 " 


" 6 to 7 " 


" 7 to 8 " 


10 " 


Not given, . 


Time of death after 


operation. 


Within 24 hours, 


On 2d day, 


" 3d " 


" 4th " 





Number. 


Kecovered. 


Died. 




. 8 


1 


7 




. 29 


5 


24 




. 26 


4 


22 




. 34 


11 


23 




. 9 


2 


7 




. 1 


1 







. 3 





3 




. 1 





1 




. 55 


15 


40 




166 


39 


127 


imber o 


f Time of death after 


Number of 


cases. 


operation. 




cases. 


19 


On 5th day, 


. 


. 9 


7 


" 6th " 


. 


. 4 


16 


" 7th " 




. 2 


15 


" 9th " 




. 1 




From 10th to 31st day, 


5 



Total, . . .78 



TREATMENT. 515 

The following were the causes of death, as given in the records of 
seventy-three cases : — 

In Operation, .... 1 Pneumonia, 5 

Apncea from too late operation, . 6 Broncho-pneumo. and pul. gangrene, 1 

Apnoea, . . . . .3 Pulmonary oedema, .... 1 

Anaemia and exhaustion, . . 4 Pseudo-membranous bronchitis, . 18 

Diphtheria, . . . 8 Tuberculosis, 1 

Bronchitis, . ... .6 Convulsions, . . . . .2 

Broncho-pneumonia, . . .15 Emphysema, . . . . .2 



Total, 



The following table gives the result of tracheotomy in one hundred 
cases. It is prepared from the statistics of Giiterbach, lately published: — 

Age. Result. 

Under 1 year, .1 case fatal. 

Between 1 and 2 years, . . . . .1 " 

" 2 and 3 " 33^ per cent, recovered. 

3 and 4 " 40 

" 4 and 5 " . . . . . 38^ " 

5 and 6 " 44| " 

" 6 and 8 " 14$ " 

8 and 9 " 25 

From conversations which I have had with surgeons of New York, I 
am persuaded that the above tables present a more favorable result than 
could be furnished by the general surgical practice of this city. Most 
New York surgeons, however, seem to shun the operation and regard it 
with ill favor, and, did they operate as frequently as those whose names I 
have mentioned, possibly the result would be better. Statistics in Paris 
probably give nearly the true proportion of successful and unsuccessful 
operations of tracheotomy for croup, as it is performed by skilful and 
careful surgeons. Of 388 cases occurring in the practice of several 
Parisian surgeons, 346 died and 42 recovered; while in the Hdpital Sainte 
Eugenie, of 374 operated on, 310 died. (Bouchut.) 

The facts in reference to tracheotomy in croup are the following : The 
majority of those operated on do not recover, but some live who without 
the operation would die. The operation is now more successfully per- 
formed than formerly, as the conditions of successful operation are better 
understood. Those who have operated several times, confess that their 
last cases did better than their first. Trousseau's experience was striking 
and instructive in this respect. No one, probably, ever performed this 
operation for croup more times than he, and, from constantly greater suc- 
cess, he became more and more an advocate of the operation. Trache- 
otomy, if properly performed, does not in any case shorten life, but it 
frequently prolongs it several days. It diminishes greatly the dyspnoea, 
and renders death easy. 



516 PSEUDO-MEMBRANOUS LARYNGITIS. 

The objections to the operation are partly of a moral nature. The 
parents, already in the extreme of grief on account of the suifering and 
probable death of the child, consent with reluctance to an operation which 
promises not cure, but a prolongation of life. Common sympathy with 
the child and regard for the emotions of the parents should certainly 
have an influence in deciding for or against the operation. The first case 
of tracheotomy which I witnessed was such as, if common, would con- 
demn this operative measure entirely. No anaesthetic was given, and, in 
the midst of the struggles of the child, large veins were severed, from 
which an abundant hemorrhage occurred. The trachea was opened, but 
this was no sooner done than death occurred, partly from the loss of blood, 
and partly from the obstruction to respiration caused by its entrance into 
the bronchial tubes. Such cases are, however, quite exceptional. Death 
rarely occurs during the operation, unless the patient is already moribund, 
and the possibility of such a result should have little weight in our decision 
for or against the operation. 

Few will deny, in the light of statistics, that tracheotomy is, in certain 
cases, proper, and that a physician at times would be culpable if he did 
not strongly urge its performance. There are certain supposed contrain- 
dications. One is age less than two years. It is true that those under 
the age of two years are less likely to recover after the operation than 
those above that age ; still, tracheotomy has now and then saved the lives 
of the youngest infants who have croup. The possibility, therefore, of 
success justifies the performance of the operation, however young the 
infant, when the only alternative is death. In the foregoing statistics it is 
seen that one of eight recovered who were under the age of two years. 

The presence of capillary bronchitis or pneumonia does not positively 
contraindicate tracheotomy, though it diminishes greatly the chances of a 
favorable issue. Nor is tracheotomy forbidden by the extension of the 
false membrane into the bronchial tubes, since it diminishes the amount of 
obstruction along which the air passes in order to reach the lungs, and the 
muco-pus as well as pseudo-membrane, lying below the point of operation, 
may be expectorated through the aperture. A decidedly asthenic state, as 
after measles or scarlet fever, indicated by feeble pulse and other symp- 
toms of exhaustion, may or may not contraindicate the operation, whether 
the pseudo-membrane is limited to the larynx and trachea or is more 
extensive. 

The manner of performing tracheotomy and the subsequent treatment 
pertain to surgery, and are described in surgical works. A skilful surgeon 
should, indeed, be employed to perform the operation when it is practi- 
cable. At what time in the course of the disease tracheotomy should be 
resorted to is an important practical question. Trousseau at one time 
recommended it as soon as there were certain evidences of the presence of 



TREATMENT. 517 

a pseudo-membrane, but in the latter part of his life he did not operate so 
early. The correct rule, in my opinion, is not to operate till there are 
signs that the blood is not sufficiently oxygenated, such as lividity of the 
prolabia and tips of fingers. When these signs occur, it is unsafe to delay 
long. The arrangements should be previously made, that no time be lost. 

It is an interesting fact that a large proportion of those who die after 
tracheotomy, die of bronchitis, usually capillary, or of pneumonia developed 
after the operation. These diseases seem to be partly attributable to the 
operation, or, if previously existing, to be aggravated by it. It is believed 
that the introduction into the bronchial tubes and the lungs of cool air, of 
air not warmed by the natural circuit through the nostrils and larynx, 
may be a cause of these inflammatory complications. Sometimes, also, the 
canula by pressure increases the inflammation of the surface on which it 
lies. Therefore, not only does the operation require skill in its perform- 
ance, but much of its success depends on the subsequent management. 
After the operation, the temperature of the apartment should be kept 
constantly at from 85° to 90°, and loaded with moisture. This obviates 
in part, but only in part, the tendency to bronchitis and pneumonia. Con- 
stant attention should be given to the canula, to prevent its filling with 
mucus and pus. Most surgeons use a double canula, which can be readily 
cleaned by removing the internal cylinder. The nurse, when properly 
instructed, can remove this cylinder as often as may be necessary in 
order to clean it. Mr. Lawrence, of London, and, following him, some 
other surgeons, prefer not to use the canula. The edges of the wound are 
kept apart by a wire which passes around the neck, or a little of the 
trachea is removed so as to produce a sufficient aperture. The reader is 
referred for particulars regarding this mode of operating to recent treatises 
on operative surgery. 

After the operation no more medication is required. The patient should 
be kept quiet and free from excitement. His diet should be mainly liquid, 
and of the most nourishing character. In a few days, if the symptoms 
abate, the aperture may from time to time be closed with the finger after 
the withdrawal of the canula, in order to ascertain if the larynx is free 
from obstruction. If bronchitis or broncho-pneumonia arise, the oil-silk 
jacket, with counter-irritation to the chest, is required, and quinine, 
digitalis, carbonate of ammonia, and alcoholic stimulants should be 
ordered. 



518 BRONCHITIS. 



CHAPTER IY. 

BRONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the 
most frequent disease of early life. It is usually associated with more or 
less inflammation of the mucous membrane of the nostrils, larynx, and 
trachea. We designate the disease coryza, laryngitis, or bronchitis, ac- 
cording as one or the other inflammation predominates. Sometimes bron- 
chitis occurs with but slight inflammation elsewhere, and often the coryza 
and laryngitis abate while the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The 
secondary form is common in connection with measles, hooping-cough, 
pneumonia and pulmonary phthisis, and it is not uncommon in scarlet 
fever, variola, remittent and continued fevers. Bronchitis is acute, sub- 
acute, or chronic, and according to its extent it is mild or severe. If the 
smallest bronchial tubes are involved, the inflammation is designated ca- 
pillary bronchitis, a term not well chosen, but which it is convenient to 
employ in a description of the malady. Bronchitis is commonly bilateral, 
affecting the tubes on the two sides with about equal intensity. When 
due to tubercles, or to pneumonia, it is apt to be unilateral, being con- 
fined to those tubes or nearly to those which are surrounded by tubercular 
or inflammatory product. 

Causes. — The causes of secondary bronchitis are obviously the diseases 
in connection with which it occurs. The cause of primary bronchitis is 
the same as that of simple acute laryngitis or coryza, namely, sudden 
change of temperature from warm to cold, exposure to currents of air, the 
practice of sending children without sufficient clothing from heated rooms 
into the open air, the throwing off of bedclothes at night, etc. Dentition 
is also an occasional cause, since some children have attacks which coincide 
with the eruption of the teeth. The cough of dentition is usually purely 
a nervous affection ; but in other instances it is accompanied by more or 
less mucous secretion, and is evidently dependent on a mild catarrh. 

Anatomical Characters — In the most common form of bronchitis, 
the larger bronchial tubes only are affected. They are the seat of the in- 
flammation in most of those cases which are designated " colds" by families, 
and which are often treated without the aid of the physician. The lining 
membrane of the bronchial tubes presents the ordinary anatomical char- 
acters of mucous inflammations. It is reddened uniformly or in patches, 



BRONCHITIS. 519 

intensely, or in that milder degree known as arborescence, according to 
the severity of the inflammation. 

The secretion of the muciparous follicles is at first arrested, and the 
surface of the membrane is dry. In the course of a day or two the 
secretory function is re-established, and the surface is covered with thin 
and transparent mucus. A day or two later, the secretion becomes 
thicker, consisting of mucus and pus. Mixed with these substances are 
epithelial cells, which are exfoliated in abundance from the inflamed 
surface. At the same time the mucous membrane becomes thickened and 
more or less softened. If the inflammation is severe, the vessels of the 
submucous connective tissue are also injected. 

Usually, in about a week in the young child, in from one to two weeks 
in older children, the inflammation begins to abate. Gradually the in- 
flamed membrane returns to its normal consistence, thickness, and vascu- 
larity, and with this return to the healthy state the muco-purulent secre- 
tion abates. 

In this, which is the simplest form of bronchitis, and most common, 
there is no ulceration, and rarely any pseudo-membranous formation, if 
the disease is idiopathic. Pseudo-membranous bronchitis is not unusual 
as an accompaniment of pseudo-membranous laryngo-tracheitis, 

Were bronchitis limited to the larger bronchial tubes, it would indeed 
be a simple affection, but unfortunately it has a tendency to extend down- 
wards. Commencing in the larger, it gradually invades the smaller tubes 
in a similar manner to the extension of erysipelas upon the skin. More 
rarely the inflammation commences simultaneously in the larger and 
smaller tubes. Now the gravity of bronchitis is proportionate to the de- 
gree of its extension downwards. It may stop at any point in its progress, 
but if it reach the smaller tubes it is one of the most serious affections of 
early life. 

The mucous membrane of the minute tubes, those next to the air-cells, 
is delicate, with but little submucous connective tissue, and it frequently, 
at post-mortem examinations, does not present to the eye those distinct 
inflammatory changes which are observed in tubes of large diameter. It 
is sometimes not notably thickened, nor its vascularity much increased, 
even when there is reason to believe from the symptoms that it was the 
seat of active phlegmasia. As we pass from these minute tubes to those 
of larger calibre, the inflammatory lesions become more distinct. The 
inflammation produces minute and abundant points of redness, and the 
membrane is evidently thickened; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age of 
three years, and since in capillary bronchitis a large proportion of them 
are inflamed, the source of the danger is apparent. It is with difficulty 
that the patient with capillary bronchitis can, by the effort of coughing, 
free the tubes from the secretions which are constantly collecting in them. 



520 BKONCHITIS. 

In weakly children, under the age of two years, expectoration is most 
difficult, and hence the great and increasing dyspnoea from which such 
patients suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those 
in which the small as well as large tubes are inflamed, the following an- 
atomical changes commonly occur : The muco-purulent secretion, which is 
tenacious, collects more rapidly in the smaller tubes than it is expectorated 
by the child, whose strength begins to be exhausted. The accumulation 
of the secretion is chiefly in the tubes which lie in the posterior and 
inferior portions of the lung. As the obstruction from the muco-pus 
increases in these tubes, less and less air passes through them into the 
alveoli with which they communicate, while the quantity of air which 
passes through the unobstructed tubes into the anterior and superior por- 
tions of the lung is proportionately increased. The effect, as regards the 
state of the lung, is obvious. In cases having a fatal issue, and in which 
we are therefore able to inspect the lesions, we find that the lower and 
inferior portions of the organ, from which air was to a greater or less 
extent excluded, have a diminished crepitation, that they lie a little below 
the general level, or that certain lobules do, and that they present a con- 
gested appearance, for while they contain too little air they have an excess 
of blood. We shall also find that the upper and anterior parts of the 
organ, perhaps the entire upper lobe, contain more than the normal quan- 
tity of air, so as to rise above the general level. There is distension of the 
alveoli in these parts, so that they are probably visible to the naked eye, 
and may appear to be emphysematous, but this is a state distinct from 
emphysema. It is merely an inflation of the alveoli to nearly their full 
capacity. 

Here and there, in the portion of lung in which the inflation has been 
incomplete, lobules may be observed which are entirely collapsed, having 
a dusky red color and no crepitation ; while in other parts, if the bronchitis 
has continued some days, there may be nodules of pneumonia. The incised 
surface of those portions of the lung to which the access of air has been 
prevented, whether they are collapsed fully, or partially, or not, has a 
reddish color from congestion, and is moist from serum and blood. On 
compressing the lung, the muco-purulent secretion appears upon the sur- 
face in points, having escaped from the divided ends of the tubes. For 
other facts relating to atelectasis, the reader is referred to the chapter in 
which this malady is described. 

Exceptionally even when not accompanied by laryngeal croup, fibrin- 
ous exudation occurs in the bronchial tubes, forming a delicate film, here 
and there, and readily detached from the surface underneath, while in 
rare instances it occurs as a firm and continuous membrane, forming a 
mould of the tubes, increasing greatly the dyspnoea, and constituting a true 
bronchial croup. If the patient with capillary bronchitis survive, the 



ANATOMICAL CHARACTERS. 521 

inflammation of the mucous membrane soon begins to abate. The tubes 
which have been the seat of the disease, and the alveoli which have been 
secondarily involved, may return to their normal state almost immedi- 
ately ; but in other instances such anatomical changes occur in them, even 
when there is no pneumonia, nor atelectasis, that full restoration to their 
normal state is necessarily somewhat slow. When the function of a lobule 
ceases, as it does when the tube leading to it is obstructed, not only hy- 
peremia occurs with or without collapse, as already stated, but its cells and 
nuclei, and perhaps other parts, begin to undergo fatty degeneration. These 
elements become granular, somewhat enlarged and opaque, and here and 
there mixed with them are other large cells filled with oil-globules. These 
are the compound granular cells of pathologists, and, occurring in this 
situation, are produced by metamorphoses of the epithelial cells. They 
are epithelial cells which have progressed more rapidly than others in fatty 
degeneration, having reached that stage of it which immediately precedes 
liquefaction. We often with the microscope observe not only these cor- 
puscles, but their fragments as they are dissolving. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had capillary 
bronchitis, and pathologists are not agreed as to the mode in which they 
are produced. Some of them, if not all, are evidently connected with the 
minute bronchial tubes, and the quantity of pus contained in each is not 
usually more than one or two drops. The most reasonable view of their 
causation is that they are produced in the terminal tubes where the mucus 
and pus collect. The pus acts as an irritant and causes inflammation, and 
the inflammation increases the quantity of pus. The walls of the tube 
which is now the seat of an abscess are destroyed by ulceration, and prob- 
ably, also, some of the contiguous air-cells. The little cavity is soon sur- 
rounded by a delicate membrane, the same in character, though less thick 
and firm, as that which constitutes the walls of larger abscesses. The 
pus presents the usual appearance of this liquid, or it may be tinged by 
the presence of blood-cells, or again it may be thick from partial absorp- 
tion of the liquor puris so as to resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. In 
certain cases it approaches the surface of the lungs, so as to produce cir- 
cumscribed pleurisy, with adhesion of the costal and visceral pleura. At 
the autopsy of such a case, on separating the adhesions and attempting in- 
sufflation, the air passes through the aperture, so that the lung on that side 
cannot be inflated unless the aperture is closed. Occasionally pneumo- 
thorax results from opening of the abscess into the pleural cavity. 

In severe protracted bronchitis dilatation of certain of the bronchial 
tubes sometimes results. The alveoli in the upper lobes may also be dis- 
tended beyond their physiological capacity, so as to produce emphysema, 
but as we have stated above, their maximum distension within physiolo- 



522 BRONCHITIS. 

gical limits, must not be mistaken for emphysema. Emphysema in the 
upper lobes is common in feeble young children, with relaxed and weakened 
tissues, occurring even without any severe disease of the respiratory organs. 
It maybe vesicular or interstitial. If it is interstitial the sacs of air often 
attain considerable size, lying as wedges between the alveoli, or like little 
bladders upon the surface of the lung. It is not difficult to understand how 
emphysema occurs in capillary bronchitis, since the air partly arrested in 
the tubes leading to the lower lobes enters the upper lobes in increased 
volume and force. 

Symptoms. — It is evident, from the description which has been given of 
the anatomical characters of bronchitis, that its symptoms vary greatly in 
severity in different patients. It usually commences with more or less 
coryza. The symptoms are headache, flushed face, elevation of tempera- 
ture, acceleration and fulness of pulse. In the mildest cases these symp- 
toms are scarcely appreciable. The child is observed to sneeze and have 
some defluxion from the nostrils, and this is followed by an occasional 
mild, almost painless, cough, which declines in the course of a few days. 
The respiration and pulse are scarcely accelerated, and the appetite is but 
slightly impaired. There may be a little fretfulness, but the child is not 
confined to his bed or room, and usually amuses himself with his play- 
things. Auscultation in these mild cases reveals coarse mucous rales in 
the larger bronchial tubes, while the smaller tubes are free from mucus. 
Sibilant and sonorous rales are also observed, especially in the commence- 
ment of the bronchitis, at w^hich time the secretion of mucus is suppressed 
or scanty. The cough in the commencement is for the same reason dry. 
It becomes looser by the second or third day, the sputum consisting of 
frothy mucus, with the admixture of pus and epithelial cells. The pus 
becomes more abundant as the disease continues. Expectoration from the 
mouth does not usually occur till after the age of four or five years ; under 
this age the sputum is ordinarily swallowed. 

The mild form of bronchitis described above, that in which only the 
larger bronchial tubes are affected, is common at all periods of infancy and 
childhood, but a severer grade of the disease is also of common occurrence, 
exclusive of those cases in which the minute branches of the bronchial tree 
are affected. It has already been stated that there is a tendency in bron- 
chial inflammation to extend downwards, and symptoms are proportionate 
in gravity to the degree of this extension. In severe bronchitis the pulse 
rises to 120 or 130 per minute, and the respiration is in a corresponding 
degree accelerated. The cough is frequent and painful, the pain being 
referred to the sternum, and often there is a steady dull pain in this region. 
The face is flushed and indicative of suffering, the temperature is consider- 
ably elevated, and the appetite is greatly impaired or lost. There is fre- 
quently an exacerbation of symptoms in the latter part of the day. De- 



SYMPTOMS. 523 

pression of the infra-mammary region during inspiration, and dilatation of 
the aire nasi, accompany grave attacks o the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales in all 
parts of the chest, sibilant and sonorous sparingly, coarse mucous and 
subcrepitant more abundantly. 

Capillary bronchitis or suffocative catarrh, the most dangerous form of 
this inflammation, is less frequent than bronchitis, which is limited to the 
larger tubes, or to the larger tubes and those of medium size. It may com- 
mence quite abruptly, but ordinarily it results from the milder form of the 
disease. The symptoms at first are such as occur in the common form of 
bronchial inflammation, but instead of abating or remaining stationary, 
they gradually increase in severity till, suddenly, marked dyspnoea super- 
venes. The inflammation has now reached the minute tubes, and what 
promised to be an ordinary attack of bronchitis becomes one of great 
severity and danger. 

The respiration in capillary bronchitis is short and hurried. Sixty to 
eighty inspirations per minute are not infrequent, while the pulse also is 
greatly accelerated, attaining as high a number as 140 to 160 or 180 beats 
per minute. The cough is frequent, and the sputum, which collects in 
abundance, is expectorated with difficulty. If expectorated so as to be 
examined, it is found to consist largely of frothy mucus with epithelial 
cells. After a few days, if the patient live, it becomes more purulent. 
Sometimes, as in bronchitis of the adult, streaks of blood appear upon the 
mucus. In the first days of capillary bronchitis, the temperature is con- 
siderably elevated, the face flushed and indicative of suffering. The patient 
is restless, moving from one part of the bed to another, seeking in vain 
for relief. The digestive function is impaired, as in all severe inflamma- 
tions ; the tongue is moist and covered with a light fur ; the appetite is 
nearly or quite lost. The nursing infant nurses with difficulty, frequently 
relinquishing the breast on account of the dyspnoea ; older children take 
no solid food in consequence of the anorexia and the dyspnoea, and even 
drinks are swallowed hastily and apparently without relish, since degluti- 
tion interferes with respiration. On auscultation in capillary bronchitis, 
at first sibilant, and after a day or two subcrepitant, rales are observed in 
every part of the chest. Percussion elicits a good resonance, unless the 
substance of the lung has become involved. As the disease approaches a 
fatal termination, the pulse becomes greatly accelerated, the respiration is 
also in a corresponding degree frequent and panting, the inspiration being 
accompanied by marked infra-mammary depression and dilatation of the 
alee nasi. The face becomes pallid, the prolabia livid, and the tips of the 
fingers livid and cool. The mucus and pus, accumulating in the air-pas- 
sages, increase more and more the obstruction to the entrance of air, and, 
finally, death occurs from apnoea. The nursing infant usually ceases to 
nurse for several hours before death, and a state of stupor commonly pre- 



524 BEONCHITIS. 

cedes the fatal event, due to the accumulation of carbonic acid in the blood. 
In young infants, especially those under the age of six months, not only 
in capillary bronchitis, but in severe ordinary bronchitis, I have often 
observed, toward the close of life, intermission in the respiration. It 
occurs after every six or eight or ten respirations, and equals in duration 
the time occupied in, perhaps, half a dozen respiratory movements. It is, 
therefore, an unfavorable prognostic, but some recover by stimulation in 
whom it occurs. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form, the patient is convalescent after three 
or four days, and, in severer forms that terminate favorably, the disease 
begins, ordinarily, to decline by the close of the first week or in the second. 
The progress of bronchitis is somewhat more rapid in young children than 
in those of a more advanced age. When convalescence is fully established, 
it is not unusual for the cough to continue three or four weeks, though 
gradually declining. It is loose and painless, and is scarcely regarded by 
the patient. 

Death sometimes occurs as early as the second or third day in capillary 
bronchitis. The younger the infant, with the same extent and intensity 
of inflammation, of course the sooner the fatal result. The ordinary dura- 
tion of fatal bronchitis is from six to eight days. If the patient pass beyond 
the tenth day, decline of the inflammation may be confidently expected, 
and recovery, unless there is a complication. 

Occasionally bronchitis becomes chronic, lasting several months before 
it entirely ceases. The chronic form may result from mild, as well as 
severe, bronchitis. The active fever and accelerated respiration which 
characterize the acute affection abate, and the general health is nearly 
or quite restored ; but an occasional cough continues, and the respiration 
is often audible, from the mucus which collects in the tubes, or from 
thickening of the mucous membrane. Sometimes there is moderate febrile 
movement, especially in the latter part of the day. On auscultation, 
coarse mucous, with perhaps sibilant and sonorous, rales are observed in 
the chest. 

There is great liability in chronic bronchitis to exacerbations. The dis- 
ease often seems to be abating, and there is prospect of its speedy cure, 
when all the symptoms are intensified. The exacerbations are due to the 
fact that the bronchial surface, when it has been a considerable time 
inflamed, is very sensitive to the impression of cold. Even when the dis- 
ease is entirely relieved, it is very apt to return by exposure to currents of 
air or changes of temperature. Chronic bronchitis occurs most frequently 
in the winter and in the spring and fall, when the weather is changeable, 
and is most intractable in these periods of the year. Many cases of 
chronic bronchitis are associated with dilatation of the bronchial tubes or 
with emphysema. The general health in chronic bronchitis, when not 



DIAGNOSIS — PROGNOSIS. 525 

dependent on a tubercular deposit, ordinarily remains good. Tubercular 
bronchitis, which is the result of a grave disease, does not require sepa- 
rate consideration. It is attended with emaciation, and is obstinate on 
account of the nature of the primary affection. It is due to the irritating 
effect of tubercular matter lying against the bronchial tubes. 

Diagnosis Bronchitis can ordinarily be diagnosticated by the char- 
acter of the respiration and cough. The absence of hoarseness, stridulous 
inspiration, and croupy cough, excludes laryngitis ; and the absence ot 
the expiratory moan and of the stitchlike pain on coughing, which char- 
acterize pneumonia and pleurisy, excludes those diseases. Accurate diag- 
nosis, however, can be most readily made by percussion and auscultation. 
Examination of the chest enables us to state with positiveness, not only 
the nature, but the extent of the affection. If the inflammation is con- 
fined to the larger bronchial tubes, coarse rales are discovered in them, 
while finer mucous rales are absent. If the bronchitis is capillary, sub- 
crepitant rales are discovered in the smaller tubes. Percussion gives clear 
resonance on both sides, except in those instances in which collapse or 
pneumonia has supervened. 

Prognosis Bronchitis, limited to the larger bronchial tubes, or to 

these and those of medium size, terminates favorably in a large majority 
of cases. Occasionally, severe inflammation, not extending to the smaller 
tubes, proves fatal in young infants, or those of feeble constitution. True 
capillary bronchitis is, on the other hand, a disease of great danger. It 
may be fatal at any period of childhood, but the younger the patients and 
more feeble, the greater the proportion of deaths. Under the age of one 
year, it is one of the most fatal diseases of early life. 

The prognosis, in the commencement of all cases of bronchitis of aver- 
age severity in the young child, should be guarded, on account of the 
tendency of the inflammation to extend, as has been already stated in the 
preceding pages. After five or six days extension ceases, and, if during 
that time there is no increase in the severity of symptoms, the prognosis 
is favorable. Signs which indicate an unfavorable result are increasing 
frequency of pulse and respiration, difficult and scanty expectoration, 
restlessness, a countenance indicative of suffering, and a progressively 
greater accumulation of mucas in the bronchial tubes, as determined by 
auscultation. Pallor and coldness of the face and extremities, lividity of 
the tips of the fingers, rapid and feeble pulse, drowsiness, diminution of 
cough, while the mucus and pus accumulate in the bronchial tubes, and, 
in young children, intermissions in the respiration, indicate the near 
approach of death. Cases may, however, recover by proper treatment, 
although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bronchitis. 
This disease, when fully established, continues a certain number of days, 
whatever remedial measures are employed, and, if the symptoms do not 



526 BRONCHITIS. 

increase in severity during the first five or six flays, a favorable result is 
highly probable. The prognosis in chronic bronchitis is ordinarily favor- 
able, so far as life is concerned, provided that there is no emaciation. If 
there is emaciation, the bronchitis may be due to tubercles in the bron- 
chial glands or lungs, and, of course, the prognosis is unfavorable. 

Treatment — Bronchitis may be rendered much milder, and perhaps 
even prevented, by an emetic employed in the first twelve or twenty -four 
hours, in conjunction with a warm bath. The physician is not, however, 
ordinarily called sufficiently early to render this treatment effectual. The 
remedial measures proper for this disease vary greatly, according to the 
stage and intensity or extent of the inflammation and the age of the 
patient. Bronchitis, limited to the larger tubes, requires simple measures. 
A laxative may be employed, with a mild expectorant, and moderate 
counter-irritation should be produced by camphorated oil, or the occa- 
sional employment of a sinapism. I have sometimes ordered for these 
cases a mixture recommended by Dr. James Jackson, of Boston, in his 
letters to a young physician. " For young children," .... says he, " I 
employ the following : Take of either almond or olive oil, of syrup of 
squills, of any agreeable syrup, and of mucilage of gum acacia, equal 
parts, and mix them. Of this mixture, a teaspoonful may be given to a 
child at two years of age; a little less if younger, and increased if older, so 
as to double the dose to one in the sixth year. This may be given from 
three to six times in the twenty-four hours. Sometimes a little opiate 
must be added at night to appease an urgent cough." These cases also do 
well with simple mucilaginous drinks in conjunction with gentle'aperients. 

Bronchitis, extending beyond the primary or secondary bronchial divi- 
sions, requires more careful watching and more decided measures. The 
abstraction of blood by leeches, or otherwise, is seldom required in the 
treatment of bronchitis. Occasionally, if the inflammation is intense and 
the symptoms urgent, moderate abstraction of blood at an early period 
might perhaps be useful, but the employment of cardiac sedatives as 
aconite or digitalis under such circumstances is generally preferable. 

As a rule, actively depressing agents should be avoided in the treatment 
of bronchitis in patients under the age of two years ; and, on the other 
hand, sustaining remedies are in a large proportion of cases required after 
the first two or three days. Many infants with bronchitis are sacrificed in 
consequence of the old theory, which still influences medical practice, that 
an inflammation, with its increased force of circulation, is necessarily best 
controlled by depletory and sedative measures. Remedies too depressing 
are prescribed, and with a less favorable result than would follow the use 
of sustaining measures or even a strictly expectant course of treatment. 

What is, therefore, the proper mode of treating bronchitis, severe or of 
ordinary gravity, occurring in infancy and childhood? It is supposed that 
the physician is called when the inflammation is fully established, or that, 
if he has seen the patient at the commencement, and has prescribed an 



TREATMENT. 527 

emetic, it has failed to throw off the disease. A large emollient poultice 
not thicker than the cover of a book, so wet as to produce constant mois- 
ture of the surface, and sufficiently irritating to produce constant redness 
without necessitating its removal, should be applied to the front and sides 
of the chest, and over it an oil-silk jacket placed. I prefer a poultice of 
the following : — 

R. Pulv. sinapis, ^ss ; 

Pulv. semin. lini, ^viij. Misce. 

Local treatment in bronchitis is very important. The exact mode of 
applying it, or the substances used, matters little, provided that it meets the 
indication, which is twofold, — namely, derivation to the surface, and the 
application to it of warmth and moisture. Such applications are found, 
by experience, to give most relief. Warmth and moisture are furnished by 
cataplasms most conveniently, or by warm water applications under oil-silk. 

Derivation to the surface, early made and repeated, tends to check the 
downward extension of bronchitis ; but it is not advisable to vesicate, or to 
produce anything more than moderate and continued redness. Often im- 
provement in symptoms is observed, especially less dyspnoea and restless- 
ness, immediately on the employment of the local measures recommended 
above. If the bronchitis have that severity that there is a decided febrile 
movement, accelerated respiration or pain on coughing, this external 
treatment should in my opinion always be employed, but if the disease is 
so mild that these symptoms are absent the case will probably do well 
without it. The internal treatment appropriate for bronchitis varies ac- 
cording to the age of the patient and the character of the inflammation, 
whether it be primary or secondary. The following formulae will be found 
useful : — 

R. Ammon. carbonat., gr. viij ; 
Syr. bal. tolut. , §ss ; 
Aquae, §iss. Misce. 
Dose, one teaspoonful every two or three hours for an infant of three months. 
Instead of the carbonate, twice its quantity of muriate of ammonia may be pre- 
scribed. 

Infants of this age usually require also alcoholic stimulants, as six or 
eight drops of brandy every hour or two. 

R. Spts. aether, nitr., 3J ; 
Syr. ipecacuanhas, 
01. ricini., aa 3*j ; 
Syr. bal. tolut., 3 y ij- Misce. 
Dose, one teaspoonful every two to four hours to an infant one year old with 
acute primary bronchitis. 

R. Syr. ipecacuanhas, 3D ; 
Potas. acetat., gr. xvj~3ss ; 
Syr. simplicis, 5~x.iv. Misce. 
Dose, one teaspoonful to an infant of six months with acute primary bronchitis. 



528 BRONCHITIS. 

Medicines which exert a greater controlling effect upon the action of 
the heart than those which we have mentioned, are often required during 
the progress of severe bronchitis, namely, in those cases in which the pa- 
tient is weakly, while the pulse is unusually rapid and temperature ele- 
vated. One or two drops of tincture of digitalis may be added as a heart 
tonic to each dose of the prescription for a patient of six months to two 
years. For children over the age of two years, whose previous health 
has been good, aconite is preferable as a cardiac sedative. The following 
will be found a useful recipe for a robust child of five years : — 

I£. Tinct. rad. aconit., gtt. xvj ; 
Syr. scillse composit., 3ij I 
Syr. bal. tolut., ^xiv. Misce. 
Dose, one teaspoonful from two to four hours. 

The medicine should be omitted or given at a longer interval if the fre- 
quency of the pulse is reduced. I have nearly abandoned the use of vera- 
trum viride for the bronchitis of children on account of its very depressing 
effect. If there is restlessness, Dover's powder, paregoric or syrup of poppy 
should be administered with the expectorant mixture or separately. 
Squibb's liquid Dover's powder, the tinct. ipecac, comp., is a useful and 
convenient remedy to procure sleep in these cases. It may be given to an 
infant of one year in one-drop doses. Agents more depressing than ipecac- 
uanha should not be administered to infants under the age of six months, 
even in the commencement of acute bronchitis. 

The effect of the stronger cardiac sedatives, as aconite and veratrum 
viride, in the bronchitis of children, should be carefully watched. In gen- 
eral they should be administered only during the first three to five days; 
but if the child is robust, with full and strong pulse, they may be con- 
tinued longer. In many cases of primary and secondary bronchitis during 
its active period, quinine administered with or without digitalis, is an 
invaluable remedy, as a substitute for aconite or veratrum viride. Like 
those agents it diminishes the temperature and the frequency of pulse, 
while it acts as a general tonic and preserves the strength of the heart's 
contractions. This effect of quinine, which has only in recent years been 
brought prominently to the notice of the profession, and is now accepted 
as a valuable fact in therapeutics, indicates an important use for this agent 
in several of the most common and severe diseases of children, as bron- 
chitis, pneumonitis, scarlatina, and diphtheria. While it may not reduce 
the frequency of the pulse as quickly as aconite, or to the same extent, it 
has in my practice been equally effectual in reducing the temperature. As 
many as six or eight grains may be administered daily in divided doses to 
a child of two or three years. If this agent is properly administered, and 
the dose reduced as the fever abates, cinchonism, at least so as to be in- 
jurious, seldom occurs. As the active inflammation begins to abate, simple 
expectorant mixtures may be given, as syrup of squills or ipecacuanha in 



TREATMENT. 529 

spiritus Mindereri. At this stage of bronchitis, it is usually best to com- 
mence the use of stimulating expectorants, and they are required in nearly 
all cases of advanced bronchitis. In secondary forms of the disease, as 
when it occurs in connection with hooping-cough or measles, such expect- 
orants should be employed from the first ; and also, if there is a state of 
feebleness or cachexia, although the bronchitis is primary. The following 
will be found useful prescriptions, the digitalis being employed as it is the 
best heart tonic with which we are acquainted, reducing the frequency of 
the heart-beats while it gives them more force : — 

R. Tinct. digital., gtt. xvi ; 
Amnion, muriat., gr. xvi; 
Syr. bal. tolut., 
Aquae, aa ^i. 
Dose, one teaspoonful every two h6*urs to a child of one year. 

R. Amnion, carbonat., gr. xvj-xxiv ; 
Tinct. digital., gtt. xxiv ; 
Syr. senega? , 5ij ! 
Ext. glycyr., 5ss ; 
Aqua?, 5 x i v « Misce. 
Dose, one teaspoonful every two or three hours to a child of two years. 

During convalescence the medicine should be administered less and less 
frequently, or in smaller doses. Emetics in ordinary cases of bronchitis 
are not required, except in the commencement. In severe bronchitis, how- 
ever, especially when the smaller tubes are inflamed, they sometimes ap- 
pear to be useful. The cases which justify their administration are those 
in which mucus and pus collect in the tubes more rapidly than they are 
expectorated, so as to give rise to urgent dyspnoea. An emetic adminis- 
tered under such circumstances may give prompt and decided relief. The 
object to be gained is obviously very different from that in the commence- 
ment of bronchitis, and such agents should be employed as act promptly, 
with the least possible depression. Turpeth mineral or sulphate of copper 
is, then, the proper emetic. The former may be given in a dose of three 
grains ; the latter, of one or two grains to a child five years old. If 
there is considerable strength of pulse and heat and dryness of surface, 
ipecacuanha may be administered. If there are evidences of exhaustion 
stimulants may be administered immediately before and after emesis. 
Infants oppressed by the accumulation of mucus and pus may sometimes 
be relieved by tickling the fauces with the finger. This provokes vomiting 
and the viscid mucus which collects at the entrance of the glottis is removed 
by the finger. 

In secondary bronchitis whatever the age, in primary or secondary 
occurring in infants or feeble children, the diet should, as a rule, be nutri- 
tious through the entire disease. Robust patients, or those who have had 
3± 



530 ATELECTASIS. 

ordinary health, if over the age of two years, and affected with primary 
bronchitis, should have light diet, chiefly farinaceous, in the first days of 
the attack, after which animal broths are proper. Whatever food is given 
in severe bronchitis must be in the form of drinks, since the appetite is 
lost, while the thirst is such that liquids are less likely to be refused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, 
and also in capillary or severe ordinary bronchitis, if there is dyspnoea 
with evidences of prostration. The occasional loose cough which is often 
present during the period of convalescence requires but little treatment. ; 
either no medicine or a gently stimulating expectorant may be given. 



CHAPTER V 

ATELECTASIS. 



In certain new-born infants the lungs do not undergo inflation, or only 
a portion of the lobules are inflated, to wit, those in the upper lobes, while 
the remainder of the organ continues unchanged from the foetal state. 
This non-inflation of the lung is designated congenital atelectasis. It is 
not due, unless in rare instances, to any defect or vice in the respiratory 
apparatus, for at the autopsies of cases which have ended fatally, as most 
cases do, at an early period, insufflation is easy, there being no occlusion 
of the air-passages, nor unusual adhesion of the walls of the alveoli to pre- 
vent the admission of air. Physicians have believed that in some instances 
they discovered the cause in an enlarged thymus gland, which compressed 
the lower part of the trachea, but this cause, in my opinion, does not exist 
or is exceptional, for although the thymus at birth is large, having nearly 
the size of an unexpanded lung, it has not seemed to me to be unduly 
enlarged in most atelectatic cases which I have examined after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness of 
inspiration, whether due to general debility, as in infants born prematurely, 
or weakened by placental hemorrhage in the last months of foetal life, or, 
as is frequently the case, to injury of the brain and consequent impairment 
of the function of the pneumogastrics during birth. I have more fully 
treated of this form of atelectasis in the chapters which relate to the mal- 
adies incidental to the birth of the child, and to these the reader is referred. 

Acquired Atelectasis, or collapse of lung, is less extensive than 
congenital atelectasis, being confined to a portion of a lobe, and often to 
only a few lobules. It occurs chiefly during the period of infancy and in 
feeble children. It is a common malady, in foundling asylums, in wasted 
infants who perish before the close of the first year. I have frequently at 



ACQUIRED ATELECTASIS. 531 

the autopsies of such infants observed it along the thin inferior margins of 
the lower lobes, and in the tongue-like prolongation of the left upper lobe. 
In this class of cases, catarrh of the bronchial tubes appears to have little 
or no agency in causing the collapse. The cause is found in the impaired 
functional activity of the lungs. In the state of debility the heart beats 
feebly and the stream of blood from it to the lungs is small and slow, so 
that the inspiration of a small amount of air suffices for its decarboniza- 
tion. The inspirations also are seen to be feeble, causing little expansion 
of the walls of the thorax. Consequently the entire lung is imperfectly 
inflated, as is seen in fatal cases, but the distant thin portions of the organ 
are least expanded. These receiving little or no air, soon begin to contract 
from the presence of the elastic tissue, and collapse or atelectasis ensues. 

This has been the most common form of atelectasis in cases of this 
malady, which I have observed in foundling asylums, and it probably 
.occurred in the manner which I have described. 

Another cause of acquired atelectasis to which all writers allude is bron- 
chial catarrh, which commencing in the larger tubes extends downwards 
into those of smallest size. By the swelling of the mucous membrane, and 
the accumulation of viscid muco-pus which cannot be expectorated, certain 
of these tubules become occluded, so that the inspired air is shut off from 
the alveoli situated beyond them. Occlusions are obviously most apt to 
occur in the bronchitis of feeble infants, whose cough has little expulsive 
force, so that debility is also a factor in the production of this form of 
atelectasis. The portion of lung withdrawn from the respiratory function 
soon collapses, the air which it contained being probably in part expired, 
but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication of 
bronchitis as was formerly supposed, for catarrhal pneumonitis due to ex- 
tension of the inflammation from the bronchioles into the lung has been 
mistaken for it. Solid non-crepitant nodules or portions of lung are fre- 
quently observed at the autopsies of infants who have perished of severe 
bronchitis, and these may be atelectatic or pneumonic, but they have in 
my observations been more frequently the latter than the former. 

The possibility of insufflating these solid portions when removed from 
the body after death, was till within a few years regarded as the decisive 
proof of atelectasis. But this is now known to be no test, since a lung 
solidified by recent catarrhal pneumonitis can be almost as readily inflated 
as that which is collapsed. Nevertheless, the inflated pneumonic lung is 
more solid and resisting when pressed between the thumb and fingers than 
is the collapsed lung. The decisive proof is afforded by the microscope, 
by which cell-proliferation is discovered within the alveoli in catarrhal 
pneumonitis, while it is lacking in simple collapse. An increase of the 
dyspnoea not infrequently occurs in severe infantile bronchitis, without 
either pneumonia or collapse from the accumulation in the bronchioles of 



532 ATELECTASIS. 

the secretion which is with difficulty expectorated, but if dulness on per- 
cussion and other physical signs indicate solidification of the lung at some 
point, of course pneumonia or collapse has occurred. If a sufficient 
amount of lung is involved to produce well-marked physical signs the dis- 
ease is in most instances pneumonia and not collapse, though it may be 
the latter. Both these pathological states may, however, occur in the 
same lung as complications of severe bronchitis. The severe paroxysmal 
cough of pertussis, especially when accompanied by considerable secretion, 
is apt to produce collapse of portions of the lower lobes, while it causes 
emphysema in the upper lobes. 

Symptoms Atelectasis resulting from bronchitis gives rise to no new 

symptoms. So far as it has any appreciable effect it aggravates certain 
symptoms of the primary disease, but as it is ordinarily limited to a small 
area this effect is not very marked. When a bronchial tube is so occluded 
by muco-pus that the alveoli with which it communicates, collapse, there 
is ordinarily, at the same time, more or less accumulation of this secretion 
in other tubes throughout the lungs. Therefore, the entrance of air into 
the alveoli with which these tubes communicate is slow and difficult, but 
usually without complete obstruction, and without true atelectasis, but 
with a semi-collapse such as we observe in fatal croup. This explains the 
dyspncea which is present in these cases. If the secretion is expectorated 
from these tubes the dyspnoea abates, even if the plug which has completely 
occluded a tube, and the consequent atelectasis remain. 

Atelectasis occurring in wasted and feeble infants, in consequence of the 
diminished force of the inspirations, does not in most instances give rise 
to any prominent symptom, since it occurs chiefly in distant thin portions 
of the lungs. I have observed an occasional short, nearly painless cough 
in such infants, when the autopsy revealed no pulmonary lesion except the 
atelectasis. 

Anatomical Characters The portion of lung which is affected with 

recent atelectasis, has a dark-brown or dark-bluish color. It is depressed 
below the general level of the lung, is firm and non-crepitant on pressure, 
and its incised surface is smooth. Hyperemia supervenes, for a portion 
of lung in which the circulation continues, but from which air is excluded, 
becomes congested. In acquired atelectasis the congestion is especially 
marked, since the vessels which have been adapted by growth for a larger 
area, are compressed into one of smaller extent, so that they become 
tortuous and bulging within the lumina of the alveoli, while the free flow 
of blood through them is retarded by the constriction of the elastic fibres 
of the lung. An obvious and certain result of the hyperemia is the 
transudation of serum into the alveoli, producing cedema. This union of 
pulmonary hypersemia with oedema by which air is excluded from the 
alveoli constitutes the state known to pathologists as splenization, and in 
proportion as it occurs, the lung depressed by the atelectasis rises towards 



TREATMENT. 533 

the general level. It may even rise above it, and it now has a doughy- 
elastic feel. The pathology of these ©edematous atelectatic spots, here- 
tofore obscure, has been clearly explained by Rindfleisch. 

If the patient live, and the atelectatic lobules do not soon return to a 
state of health, they undergo further changes. Rindfleisch says : " From 
the series" (of changes, provided inflammation do not occur) " we especially 
render prominent two conditions, inveterate oedema, and slaty induration. 
But inflammation does commonly occur after a time in a collapsed lung." 
Those who are familiar with the post-mortem examinations of infants will 
fully agree with Rindfleisch when he says : " Splenization, quite generally 
taken, appears to present extraordinarily favorable preliminary conditions 
for the occurrence of inflammatory changes. It may directly represent the 
initial hyperemia of acute inflammation, and be followed by lobular and 
lobar, but constantly catarrhal infiltrates." It is well known by patholo- 
gists that protracted congestion, active or passive, of whatever organ or 
tissue, is very apt to pass from a state of simple stasis of blood to one of 
cell-proliferation, and the atelectatic lung, as I have myself observed at 
autopsies, affords a common example of this. I have several times made 
or have procured microscopic examinations of the atelectatic portions of 
lungs of infants, who had died, for the most part, in a wasted and en- 
feebled state, and have found in them clear evidence of the presence of a 
catarrhal pneumonia. The interesting fact, therefore, must be recognized, 
that atelectasis frequently passes to a state of inflammation, so as to pre- 
sent the characters of ordinary hypostatic pneumonia, and no doubt un- 
dergo the same subsequent changes. 

Atelectasis, when recent and simple or uncomplicated, may soon disap- 
pear by the expectoration of the obstructing secretion, if such is present, 
or if there is no obstruction, by increased force of inspiration. If it do 
not soon disappear it undergoes one of the ulterior changes alluded to 
above, and henceforth the symptoms and history are those of the new 
malady which has supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it is 
recent and there is evidence that it is due to the accumulation of the 
secretion in the bronchial tubes, an emetic, which acts promptly and with 
the least possible depression, may be very useful. It is especially indicated 
if there is little or no pneumonia, the strength not greatly reduced, and 
there is dyspnoea with insufficient decarbonization of blood in consequence 
of the abundance of the secretion in the smaller tubes. An emetic which 
acts promptly and with little prostration, may aid greatly in establishing 
the respiratory function in collapsed lobules, by expelling the obstruction, 
and producing a freer and deeper inspiration. One of the best if not the 
best emetic for this purpose is sulphate of copper, given in a dose of one 
to two grains to a child of one year. \Vith or without the use of the 
emetic our main reliance must be on sustaining and stimulating measures, 



534 PNEUMONITIS. 

by which the cough, the cry, and the inspirations acquire more volume 
and force. Most cases require alcoholic stimulants and carbonate of am- 
monia. Rubefacient applications to the chest are also commonly em- 
ployed, and are probably useful. 



CHAPTER VI. 

PNEUMONITIS. 

In children over the age of three years, pneumonitis differs but little in 
form or phenomena from that of the adult, being ordinarily primary 
except as it depends on an irritant, as tubercles, and extending rapidly 
over one or more entire lobes. In those under the age of three years it 
is, on the other hand, as a rule, a secondary affection, and limited to a 
part of a lobe. Most writers, until recently, have classified cases according 
to their origin as primary and secondary, or their extent as lobar and 
lobular, or their duration as acute or chronic. A better classification, 
having an anatomical basis, is that into catarrhal, croupous, and inter- 
stitial. 

Catarrhal pneumonitis consists in an inflammation of the air-cells, with 
an abundant proliferation of epithelial cells within them, and the exuda- 
tion of serum, but not of fibrin. The secondary and lobular pneumonitis 
of young children, alluded to above, is usually of this character. Croupous 
pneumonitis consists also in an inflammation of the alveoli, but with an 
abundant formation of pus-cells within them, and the exudation of fibrin 
and serum. The lobar and primary pneumonitis of advanced children 
and adults is commonly of this character. In both catarrhal and croupous 
pneumonitis, therefore, the solidification of the lung and exclusion of air 
are due mainly to the newly formed cellular elements with which the 
alveoli are filled, though the source and nature of these cells differ in the 
two diseases. Interstitial pneumonitis consists in an inflammation and 
hyperplasia of the connective tissue of the lungs. It is the chronic pneu- 
monia of authors, resembling in many respects, in its anatomical and 
clinical characters, cirrhosis of the liver. The inflammation which pro- 
duces this result is subacute, and in nearly all cases is dependent on some 
persistent local disease in the minute bronchial tubes or lungs, as softened 
or cheesy tubercles, cancer, abscesses, protracted inflammation of the 
alveoli or bronchioles, whether produced by the inhalation of dust of an 
irritating nature or other cause. Interstitial pneumonia is much more 
rare in children than adults, and, as it presents no peculiar features in 
them, it need only be alluded to in this connection. 



causes. 535 

Causes Croupous pneumonitis in most cases results from that common 

cause of inflammations — namely, taking cold. It commences as a primary 
disease within a few hours after exposure. Catarrhal pneumonitis, in ex- 
ceptional instances, also commences abruptly as a primary disease from 
the same cause, but being, probably in nine cases out of ten, secondary, 
it commonly results from antecedent pathological states, which we will 
enumerate. 

First. Many cases result from bronchitis. The inflammation extending 
downward engages the minute bronchial tubes, and from them traverses 
the alveoli of one or more lobules. This is the broncho-pneumonia of 
children described by authors ; it occurs most frequently between the ages 
of six and eighteen months. , 

Secondly. Hypostasis, or passive congestion, is an important factor in 
the causation of many cases, and in feeble infants it is not infrequently the 
sole cause. Infants with feeble health and languid circulation, lying in 
their cribs day after day with little movement of the body, are very liable 
to passive congestion of the depending portions of their lungs, and this by 
and by eventuates in a cell proliferation within the alveoli — in other words, 
a pneumonia presenting some peculiarities, but of the catarrhal form. In 
foundling hospitals, where feeble infants are received and treated, this is 
one of the most frequent pathological states, and is the prevailing form of 
pulmonary inflammation. It is sometimes described as hypostatic pneu- 
monia. Hence physicians, whose observations have been largely in such 
institutions, have almost ignored any other form of pneumonia in infants. 
Billard, a close and accurate observer, wrote nearly half a century ago : 
" Pneumonia of infancy presents peculiar characters, in which it differs 
from the same affection in adults. Instead of being an idiopathic affection 
arising from irritation developed in the pulmonary tissue under the influ- 
ence of atmospheric causes, which often excite the disease, the pneumonia 
of young infants is evidently the result of a stagnation of blood in their 
lungs. Under these circumstances this blood may be regarded as a kind 

of foreign body It would, therefore, appear that inflammation of 

the lungs, which produces hepatization, arises in infants, in general, from 
some mechanical or physical cause." Valleix also states that he found the 
lesions of pneumonia in a majority of the infants who died in the Hopital 
des Enfants Trouves. The statements of Valleix are applicable also to 
the Infants' Hospital, and Xursery and Child's Hospital, of this city, as 
regards those cases in which death results from chronic disease. We 
shall see hereafter that hypostatic pneumonia is one of the most common 
complications of chronic infantile entero-colitis, the summer complaint of 
the cities. 

Thirdly. Catarrhal pneumonia of infants sometimes results from col- 
lapse. It is not unusual to find, at the autopsies of infants who have died 
in a state of emaciation and feebleness, portions of the lungs remote from 



536 



PNEUMONITIS. 



the bronchi collapsed, as, for example, the thin edges of the inferior lobes, 
and the tongue-like process of the upper lobe, the process which lies over 
the heart. The immediate cause of the collapse has been a bronchitis, or 
it has resulted directly from the general weakness of the infant, and its 
feeble respirations. Now, a collapsed lung soon becomes affected by 
passive congestion. The functional activity of an organ favors circulation 
through it, and if the function is abolished the flow of blood in the part is 
retarded, and stasis more or less complete results. The hypergemic state 
of collapsed pulmonary lobules presents the same anatomical condition, 
for the supervention of pneumonia, as occurs in cases of hypostatic con- 
gestion. Consequently, cell proliferation soon begins in the collapsed 
alveoli, the volume of the affected lung increases, and it becomes firmer 
and more resisting to the touch, and the microscope reveals the characters 
of a subacute but genuine catarrhal pneumonitis. I have made or have 
procured microscopic examinations of a considerable number of such 
specimens, and have found the alveoli more or less filled with cells of the 
epithelial character. 

In rare instances in infancy and childhood pneumonitis results, as it 
more frequently does in the adult, from an embolus detached from a 
clot, which had formed in some remote vein, in consequence of arrest of 
circulation in it, by inflammation of the contiguous tissues. This is de- 
scribed by writers as a distinct form of pneumonitis, designated embolic 
or embolismal. A specimen showing this mode of causation was ex- 
hibited by me at the New York Patho- 
logical Society, in February, 1868. An 
infant, born January 22d, 1868, of stru- 
mous parents, had been fretful, but with- 
out appreciable ailment till February 
3d, when inflammation of the connective 
tissue occurred on the anterior aspect of 
the left leg, a little below the knee. This 
extended downwards, suppurated, and the 
pus was evacuated February 5th. In the 
mean time three other similar inflamma- 
tions occurred, two on the right foot and 
leg, and the other over the parietes of the chest in the right infra-mam- 
mary region. Suppuration occurred in all of these. 

On February 8th this infant was suddenly seized with extreme dyspnoea, 
and died in a few hours. Numerous minute puriform collections (for- 
merly called metastatic abscesses) were discovered in each lung, most of 
them scarcely larger than a pin's head. One of them on the right side in 
the middle lobe connecting with a bronchial tube had ruptured into the 
pleural cavity, causing pneumothorax, collapse, and incipient pleuritis. 



Fig. 23. 




ANATOMICAL CHARACTERS. 537 

The annexed figure exhibits the microscopic appearance of this softened 
fibrin, which, to the naked eye, so closely resembled pus. 

On account of the speedy death, the emboli had produced, in the 
lobules where they had lodged, little more than congestion or the first 
stage of pneumonitis around them. Had the infant lived longer, doubtless 
the ferments or the vibriones, which some consider the irritating element 
of emboli, would have produced suppurative inflammation. 

Anatomical Characters — Nothing need be added in this connec- 
tion to what has already been said, in reference to interstitial and em- 
bolismal pneumonias. Being comparatively rare in children, they pre- 
sent the same anatomical characters as in the adult. That unimportant 
form of pneumonia called pleurogenous, and which consists in a croupous 
inflammation of the superficial infundibula of the lung underneath an 
inflamed pleura, occurs in children as well as adults. Being secondary to 
the pleuritis, produced by extension of the inflammation of the pleura, it 
gives rise to no physical signs, or appreciable symptoms, on account of its 
slight extent, and as it presents no peculiar features in the child, it need 
only be alluded to. 

Croupous pneumonitis, which we have stated is the ordinary form of 
pulmonary inflammation in children over the age of five years, has the 
same anatomical characters as in the adult. It ordinarily involves an 
entire lobe. It is more frequent in the right than left lung, and in which- 
ever lung it occurs its most frequent seat is the lower lobe. The inflam- 
mation may, however, be limited to an upper lobe, especially on the right 
side. It ordinarily commences near the root of the lung, and extends 
forward. 

Croupous pneumonitis presents three stages, that of congestion, red 
hepatization, and gray hepatization. In the stage of congestion the capil- 
laries in the walls of the alveoli are greatly distended, bulging forward in 
loops within the alveolar spaces so as to diminish them, and a viscid albu- 
minous fluid begins to exude, in which points of extravasated blood appear. 
The affected lung in this stage has a deep-red color, its elasticity is greatly 
diminished, and its density and weight increased. On account of the re- 
duced size of the alveoli from the bulging of the alveolar walls, and the 
viscid fluid within the alveoli and terminal bronchial tubes, the function 
of the affected lobe is nearly lost, and hence the dyspnoea which patients 
experience in the first stage of the inflammation. 

The second stage is characterized by the continued and increased escape 
of the liquor sanguinis and red and white corpuscles through the stigmata 
or little apertures which exist normally in the walls of the capillaries. 
The inflamed alveoli and the minute bronchial tubes which terminate in 
them are filled with this pneumonic exudation. The relative proportion 
of the elements of the blood in the exudate varies in different cases. 
Fibrin is always present, immediately coagulating in delicate filaments 



538 PNEUMONITIS. 

within the interstices of which the corpuscles are lodged. The white cor- 
puscles in some cases are much in excess of the red, while in others the 
red predominate. The lung in the second stage contains no air, has a 
greater specific gravity than water, is friable so as to be readily torn and 
penetrated by the finger. The torn surface in the adult presents a gran- 
ular appearance, each granule being the contents of an air-cell. In the 
child the granules are not distinct on account of the small size of the air- 
cells, but the volume of the inflamed lobe is somewhat increased as in the 
adult. 

The stage of gray hepatization succeeds, in which the volume of the 
lung is still greater. The change of color is due partly to the compression 
of the capillaries by the inflammatory material, partly to the destruction 
of the red corpuscles, and disappearance to a greater or less extent of 
their coloring matter, while the white corpuscles (pus-cells) remain, but 
more to commencing fatty degeneration in the exudate prior to its lique- 
faction. In favorable cases the lung soon returns to its normal state, the 
liquefied substance which filled the alveoli being in part absorbed, in part 
expectorated. 

Croupous pneumonitis often causes inflammation of the portion of the 
pleura which covers it. Pleuritis developed in this way is circumscribed, 
but it frequently extends beyond the inflamed parenchyma to the distance 
of one or two inches. Bronchitis is also a common accompaniment. It 
may be general, in which case it occurs independently, or be limited to the 
tubes lying within the inflamed lung, in which case it results like the 
pleuritis from the pneumonitis. It is seen from this description that the 
pus-cells which are produced so abundantly in the alveoli are believed to 
be chiefly exuded white corpuscles of the blood. Possibly some of them 
may be produced by proliferation of the epithelial cells, which line the 
alveoli, in the same manner as they are believed to be produced in the 
bronchial tubes. 

Catarrhal pneumonitis, which is, as we have stated, for the most part 
the lobular pneumonitis of writers, and which, with an occasional excep- 
tion, is the form of inflammation in children under the age of five years, 
presents not only clinical but anatomical features, which distinguish it 
from the croupous form of the disease. Those who have witnessed few 
post-mortem examinations of young children, and whose views of the 
lesion are influenced by the expression lobular, are apt to suppose that 
there is an alternation of inflamed and healthy lobules, so that the surface 
of the lung presents an appearance not unlike mosaic work. This is a 
mistake. Although an entire lobe is seldom inflamed, as in croupous 
pneumonitis, the inflammation commonly extends over more or fewer 
contiguous lobules, but we find certain lobules in the midst of the inflamed 
area which are but slightly affected or have escaped entirely. The extent 
of the inflammation is ordinarily from one to three inches, but I have seen 



ANATOMICAL CHARACTERS. 539 

a nodule of true catarrhal pneumonia not larger than a pea, while every 
other portion of the lung was healthy. On the other hand, almost an 
entire lobe may appear hepatized to the naked eye as in the croupous in- 
flammation, but by a careful examination certain lobules will be found 
unaffected. Thus, in a case in the Nursery and Child's Hospital, in Avhich 
death occurred at the age of one year from pneumonitis supervening upon 
pertussis, an entire lower lobe, with the exception of a little of its anterior 
border, presented the jappearance and feel of red hepatization, but a care- 
ful microscopic examination revealed not only the absence of fibrin in the 
exudate, showing the catarrhal nature of the inflammation, but also cer- 
tain lobules in the midst of the inflamed lung which were not involved. 

The first change occurring in a lung invaded by catarrhal pneumonitis 
is congestion, whether active, as in the common form of the disease, in 
which the inflammation has extended into the lung from the bronchioles, 
or passive, as when the inflammation results from hypostasis or collapse. 
An exudation of serum, but not of fibrin, follows, and soon the epithelial 
layer which lines the alveoli begins to swell. The nuclei of the epithelial 
cells divide, the cells themselves forming large round cells with vesicular 
nuclei. These cells, to which the solidification of the lung is mainly due, 
are, therefore, on account of their origin and appearance, regarded as 
epithelial. The alveoli in catarrhal pneumonitis, it is seen, are filled 
with an inflammatory product quite different from that in the croupous 
inflammation. 

Inflammation of the pleura over the inflamed lung, so common in croup- 
ous pneumonia, and which gives it the name pleuro-pneumonia, by which 
it is sometimes designated, rarely occurs in this disease. The seat of this 
inflammation is ordinarily the posterior part of the lungs, even when it re- 
sults from extension of the inflammation from the bronchial tubes. When 
resulting from collapse, it affects chiefly those lobules which are remote 
from the bronchi, and which the air enters only by a long circuit. 

Catarrhal pneumonitis, when it arises from extension of acute inflamma- 
tion of the bronchioles, is acute, but in those forms of the disease which 
supervene upon passive congestion it is subacute. The alveoli are less dis- 
tended by inflammatory products than in croupous pneumonia, not only 
from the absence of fibrin, but from a less amount of cells. Hence the 
volume of the inflamed lung is not so great as in that disease, and the torn 
surface, even in the adult, does not present a granular appearance. Hence, 
also, the stage of gray hepatization does not supervene so uniformly and 
regularly, since there is less compression of the capillaries in the alveolar 
walls, and the mutual pressure of the inflammatory product is less. In 
infants who have died with this form of pneumonitis, of six or eight weeks' 
duration, it is not unusual to find the affected lobules still in the stage of 
red hepatization. Cell proliferation occurs in the bronchioles of the in- 
flamed lung as in the alveoli, producing within them numerous plugs, 



540 PNEUMONITIS. 

which, though they obstruct the entrance of air, are not so firm as in 
croupous pneumonitis, as they are destitute of fibrin. 

In favorable cases the lung affected by catarrhal inflammation returns 
to its normal state, probably by the same process as in croupous pneu- 
monitis. In other cases, especially in scrofulous and feeble children, the 
inflammation, instead of resolving, passes into what is now designated 
cheesy, or by certain writers scrofulous, pneumonitis. 

Cheesy Pneumonitis — Cheesy degeneration of the inflammatory pro- 
duct occasionally occurs in the croupous form of inflammation, but it is 
more common in the catarrhal. I have most frequently observed it in 
New York during epidemics of measles, when this form of pneumonitis 
supervened upon the catarrhal bronchitis of that disease. Cheesy pneu- 
monitis is in its nature chronic, and attended with great reduction of the 
vital powers. 

Cheesy degeneration of the exudate or infiltrate consists essentially in 
the absorption of the liquid portion, and fatty degeneration of the solid. 
The obstruction of the circulation in the capillaries and the accumulation 
of cells in the alveoli and bronchioles which cannot be expectorated, are 
conditions which favor the cheesy metamorphosis. The appearance and 
consistence of the lung when it has undergone this change are well ex- 
pressed by the term which is employed to designate it. The cheesy mass 
consists of fatty, shrivelled, and fragmentary cells, and amorphous matter, 
in which can be traced the elastic fibres and larger vessels of the paren- 
chyma, the other histological elements having disappeared. 

The caseous mass after a time softens, attracting moisture from the sur- 
rounding tissues. The molecular detritus and the shrivelled cells are now 
suspended in a liquid, and, like any dead matter, they are irritant to 
the surrounding lung-substance. The bronchial tube which supplies the 
affected lobule, and which in many instances was the starting-point of the 
disease, again becomes pervious, either by softening of the plug or by ulcer- 
ation at a higher point upon its walls, and air is admitted, which promotes 
the putrefactive process and chemical changes of the caseous substance. 

The lesion now described is that of pulmonary consumption, a disease 
not infrequent in children of two or three years. There are as yet no 
tubercles, but the presence of softening caseous material in the lungs very 
frequently leads to their development (see Art. Tuberculosis), and accord- 
ingly, before the case ends, clusters of tubercles may appear in the con- 
nective tissue and walls of the vessels of the lungs and in other organs. 

In the subsequent progress of cheesy pneumonitis, if the patient live 
sufficiently long, there occurs more or less expectoration of the offending 
substance, producing a cavity. Around the cavity a vascular pyogenic 
membrane forms, upon which granulations arise. These granulations, 
which produce pus abundantly, and from which small extravasations of 
blood are frequent, are gradually transformed into connective tissue. If 



SYMPTOMS. 541 

the dead portion is expectorated, and there is a single small cavity, the 
child may recover, the empty space being finally filled up by the exten- 
sion of the granulations, and the production of a cicatrix, which contracts, 
producing a puckered appearance. Ordinarily, however, there are several 
centres of caseous degenerations, and several cavities resulting, which con- 
tinue to enlarge by the progressive softening of the cheesy matter Often, 
also, certain of the cavities intercommunicate. The bronchial glands 
undergo hyperplasia, and certain of them are apt, also, to become cheesy. 
As the disease advances, the suppuration and expectoration increase. The 
fatal result occurs sooner in children than in adults, and, therefore, the 
lesions, destructive and inflammatory, observed at autopsies, are ordinarily 
not so far advanced in the former as in the latter. Other unfavorable 
changes may occur in the hepatized lung, but cheesy degeneration is the 
most common and noteworthy. 

Whether it is possible to inflate a lung which presents to the naked eye 
the appearance of pneumonitis, has long been regarded as a reliable sign 
of the presence or absence of inflammatory consolidation. The facts as 
regards the possibility of insufflation are these : In croupous pneumonitis, 
when it has passed beyond the first stage, insufflation is impossible in the 
lung of the child as well as adult, with the utmost force of the breath. We 
produce emphysema in healthy portions of the lungs, while the inflamed 
area is not encroached upon. 

On the other hand, in catarrhal pneumonitis, which we have seen is 
the common form of pulmonary inflammation in children under the ao-e of 
three years, and in which there is less distension of the air-cells by inflam- 
matory products, the lung can be inflated, except in protracted cases, but 
when fully inflated the solidified lobules can still be felt between the thumb 
and fingers. In protracted catarrhal pneumonitis, as well as in protracted 
collapse, which, indeed, may and often does become a pneumonitis, full 
inflation is impossible. Central portions still remain impervious to air. 
While, therefore, the possibility or impossibility of inflating a lung re- 
moved from an adult, and which presents to the naked eye the appearance 
of pneumonic solidification, is a valuable sign as indicating whether or not 
the disease was pneumonitis, this test is uncertain and unreliable when ap- 
plied to the pulmonary lesions of children under the age of three years. 

Symptoms — Croupous pneumonitis commonly begins abruptly, or it is 
preceded for a brief period by symptoms of a cold. In the adult, the 
abrupt commencement is ordinarily with a chill. In the child, there is 
often a sensation of chilliness, but a distinct chill is not common. Con- 
vulsions sometimes occur in place of a chill. Catarrhal pneumonitis, beino- 
ordinarily a secondary disease, begins in a more gradual way, its symptoms 
being preceded by, and associated with, those of the primary affection. 

The symptoms of acute pneumonitis, whether catarrhal or croupous, are 
the following : Anorexia, thirst, restlessness, elevation of temperature, 



542 PNEUMONITIS. 

acceleration of pulse according to the intensity of the inflammation and the 
feebleness of the patient, flushed face, a countenance indicative of suffering, 
accelerated respiration, with an expiratory moan. These symptoms are 
constant in the acute inflammation unless of the mildest form. Those 
which are important I shall describe more fully. 

The expiratory moan is described by writers as a pathognomonic symp- 
tom of this disease, or of pleurisy. It is evidently due to the pain expe- 
rienced by the friction of the inflamed pleura. As a rule, the expiratory 
moan does indicate either pneumonitis or simple pleuritis ; but there are 
exceptions. It may occur, for example, from indigestible substances in 
the stomach and intestines, giving rise to acute dyspepsia ; or from certain 
forms of abdominal inflammation, which render movements of the dia- 
phragm painful, as diaphragmatic peritonitis. 

The cough in the first days of pneumonitis is often dry or hacking and 
painful. It afterwards, if the case is favorable, becomes looser, and is 
painless. We very seldom observe in the child the bloody sputum which 
characterizes pneumonitis in the adult, since in catarrhal inflammation 
there is little or no exudation of blood-corpuscles. The sputum, which 
in this form of the disease is the product of secretion and cell proliferation, 
is at first thin and frothy, but afterwards thicker and less tenacious from 
the greater number of cells. There is often, in the first period of the 
inflammation, pretty severe and constant headache, the patient complain- 
ing of the head, if old enough to speak, before he does of the chest. In 
a severe attack the child at this period lies with the eyes shut, apparently 
in a half-conscious state, fretful if spoken to or aroused, so that the physi- 
cian might be led to suspect the presence of cerebral disease. If there 
is vomiting, accompanied with sudden twitching of the muscles, and con- 
vulsions — symptoms which sometimes occur — the liability to error in 
diagnosis is greatly increased. Cerebral symptoms are more prominent 
in the commencement of pneumonitis than subsequently. As the disease 
advances they subside, and symptoms referable to the chest become more 
conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respira- 
tions per minute are common, and, in severe cases, the number reaches 
sixty or even eighty. In infants there is greater frequency of respiration 
than in children. In those at the breast, if the dyspnoea is urgent, nutri- 
tion is sometimes seriously interfered with, since in these severe cases 
respiration is performed more through the mouth than nostrils, so that if 
the infant seizes the nipple, it is forced to relinquish it in order to breathe. 
Dilatation of the ake nasi, and depression of the infra-mammary region, 
accompany inspiration. The dyspnoea in catarrhal pneumonitis is often 
due in great part to accompanying bronchitis. 

The temperature in mild cases of pneumonitis is elevated to about 101° 
to 103° ; in severe cases it may reach 105° or even 107°, the former being 



SYMPTOMS. 543 

the highest observed by Mr. Squire. In ninety-seven observations made 
by M. Roger, the average temperature was 104° during the active period 
of the inflammation. The face is therefore flushed, and the heat of surface 
pungent, except in weakly children, in whom, even in severe and active 
inflammation, the face is sometimes pale, and the extremities of natural or 
less than natural temperature. 

The tongue is moist, and covered with a light fur ; the thirst is such 
that nutriment may be given in the form of drinks, when the loss of appe- 
tite prevents the use of solid food. The bowels are usually constipated. 
The secretions, in the first and second stages, are diminished. The urine 
is more deeply colored than in health, and in vigorous patients it deposits 
urates on cooling. The chlorides are also deficient, or absent from the 
urine, so long as the inflammation is extending. 

In favorable cases, in from seven to ten days the heat and thirst decline ; 
the pulse and respiration gradually become less frequent ; the cough looser ; 
the features have a more placid or contented expression ; the appetite 
returns, and the patient is again amused by playthings. The improve- 
ment is progressive, but gradual. A slight cough is occasionally observed 
for two or three weeks after convalescence is fully established. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the 
respiration more oppressed, and finally, near the close of life, the face and 
extremities become cool. Occasionally death results from apnoea, due in 
great part to coexisting bronchitis. In exceptional instances it occurs 
from convulsions, followed by coma, especially in the first week. In those 
protracted cases in which the inflammatory products have undergone 
cheesy degeneration death occurs from asthenia. 

Such are the symptoms and progress of ordinary acute pneumonitis in 
children. When the inflammation is subacute, as in those forms of the 
disease which result from collapse or hypostasis, the symptoms are less 
pronounced. The respiration in such cases is but moderately accelerated, 
is attended by little pain, and therefore the expiratory moan is often 
absent. An occasional short, dry cough occurs, with so little increase of 
temperature and quickening of the pulse that the pneumonitis is apt to 
be overlooked by the physician, the symptoms being referred to bronchitis. 
Pleuritis seldom occurs in connection with this form of pneumonitis, 
except when a small abscess or gangrene results in an affected lobule 
directly under the pleura. A few such cases I have observed. 

Tubercular pneumonitis extends over much or little of the luno- accord- 
ing to the amount of tubercles. The symptoms are like those of severe 
primary pneumonitis, superadded to such as pertain to tuberculosis. This 
inflammation, when once established in the consumptive child, commonly 
continues till the close of life. I have sometimes had these cases under 
observation for several consecutive weeks, even months, and during the 



544 PNEUMONITIS. 

whole time there was not only acceleration of pulse and respiration, but 
the expiratory moan. As regards pneumonitis occurring in hooping-cough, 
it is an interesting fact that its symptoms modify those of the primary 
disease, so that, during the active period of the inflammation, the par- 
oxysmal cough diminishes, and a short, hacking cough and expiratory 
moan occur in place. As the inflammation abates, the spasmodic cough 
returns. Pneumonitis, occurring in measles, is more obstinate, protracted, 
and dangerous than the primary form. It usually commences about the 
period of the decline of the eruption, and, in favorable cases, continues 
two or three weeks. It is then a sequel, rather than complication. 

Physical Signs. — The physical signs of pneumonitis in inlancy and 
childhood are the same as in the adult, but in a large proportion of cases 
they are less distinct. In a majority of patients under the age of three 
years the crepitant rale is not observed. This is due to the small size of 
the alveoli at this age. I have now and then detected it in quite young 
children, in whom it is a finer rale than in the adult. If observed, it is, 
of course, positive proof of the existence of pneumonitis. The physical 
signs, therefore, in the first stage of the inflammation, are often obscure in 
consequence of the absence of the pathognomonic rale. The vesicular 
murmur is somewhat intensified through the chest, and there is in this sta^e 
slight dulness on percussion over the seat of the inflammation due to en- 
gorgement of the vessels, but it is difficult to appreciate this. 

In the second stage, which supervenes more or less rapidly, the physical 
signs are more distinct. Bronchial respiration is in most cases detected, 
higher in pitch than the vesicular murmur, with the sound of expiration 
higher than that of inspiration. The voice of the patient is transmitted 
to the ear applied over the seat of the disease, and often a peculiar vibra- 
tory sensation is communicated to the hand applied over the part, so that 
it is possible to locate the disease by palpation alone. There are frequently, 
in the second stage, and sometimes in the first, coarse mucous rales in 
various parts of the chest from coexisting bronchitis. 

Percussion, in the second stage, elicits a dull sound as compared with 
that produced on the opposite side of the chest. The dulness corresponds 
in extent with the solidification, and with the bronchial respiration. 

As the inflammation abates, the dulness on percussion gradually dimin- 
ishes, and the bronchial respiration is succeeded by the subcrepitant rale. 
Often, for a considerable period after convalescence is established, moist 
rales are observed in the chest, and sometimes the dulness on percussion 
does not entirely disappear till after the health is fully restored. 

In catarrhal pneumonitis these signs are commonly less distinct than in 
the croupous form of inflammation. This is due in part to the limited 
extent of the inflammation, in part, in many cases, to its subacute cha- 
racter, and in part to the fact that is apt to be double, especially in those 
cases in which it results from hypostatic congestion. 



DIAGNOSIS. 545 

Diagnosis It will aid in diagnosis to recollect that under the age of 

three years, pneumonitis is ordinarily catarrhal, and that it is preceded 
by, and associated with bronchitis. Coincident with, and often preceding 
its development for a few days, are the usual symptoms of nasal and bron- 
chial catarrh. Defluxion from the nostrils, and other symptoms due to 
'* taking cold," help us to diagnosticate catarrhal pneumonitis from the 
essential fevers, with the exception of measles. Croupous pneumonitis 
begins more abruptly, but in this form of inflammation a greater extent of 
pulmonary solidification soon gives us clear and unmistakable physical 
signs. The various forms of so-called remittent fever bear considerable 
resemblance as regards symptoms to certain cases of pneumonic inflamma- 
tion, but in the latter there is more acceleration of respiration, and greater 
suffering, especially when the child is disturbed, than in the former. The 
physical signs, however, afford the decisive proof of the nature of the 
malady, as dulness on percussion, bronchial respiration of a higher pitch 
and harsher than the normal vesicular respiratory sound, bronchophony, 
vocal fremitus, etc. 

Difficulty sometimes attends the diagnosis of broncho-pneumonitis from 
simple bronchitis. The presence of the expiratory moan, if it is pretty 
constant and marked, affords evidence that the inflammation has extended 
to the lungs, but the physical signs constitute the reliable means of exact 
diagnosis. They should be carefully noted, in order to determine if there 
is some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial respiration, 
and bronchophony. These three signs coexisting afford sufficient proof of 
pneumonitis, unless there is tubercular consolidation or possibly collapse 
supervening on suffocative bronchitis. The history of the case aids in 
determining whether there is either of* these diseases. Moreover, collapse 
occurs later after the attack commences than hepatization, and does not 
produce so distinct bronchophony or bronchial respiration as is observed 
in ordinary cases of pneumonitis. 

Pleuritis with effusion may present physical signs which bear consider- 
able resemblance to those in pneumonia ; but in pneumonia, except when 
associated with tubercular deposit, the dulness on percussion is not so 
great as that from pleuritic effusion, nor does the line of dulness vary 
according to the position of the child. In pleuritic effusion in a young 
child the respiratory murmur can often be heard with the ear applied over 
the liquid, but it is indistinct and transmitted through the liquid from a 
distance. The practised ear is able to discover the difference between it 
and the bronchial respiration of pneumonitis. Vocal fremitus, which is 
absent in pleuritic effusions, is another reliable sign of pneumonitis. Occa- 
sionally the physical signs indicate the coexistence of the pulmonary and 
pleural inflammations. 
35 



546 PNEUMONITIS. 

In catarrhal pneumonitis it is often difficult to determine certainly the 
nature of the disease, since the physical signs, if there is but little extent 
of inflammation, are absent or indistinct. I have often, in post-mortem 
examinations, found so small a part of the lung hepatized that it could 
not possibly have produced any appreciable dulness on percussion, bron- 
chial respiration, or bronchophony. Such cases are apt to pass for simple 
bronchitis, and, practically, this matters little, since the treatment required 
by the two is not dissimilar. 

Prognosis Primary pneumonitis, affecting only one lung, if properly 

treated, in most instances terminates favorably in children, and even in 
infants. If double, it is, as in the adult, much more serious, and in a large 
proportion of cases, fatal. Secondary pneumonitis, pneumonitis occurring 
in measles, hooping-cough, tuberculosis, or resulting from hypostatic con- 
gestion in the course of some exhausting disease, is, on the other hand, 
more frequently fatal. As death usually occurs from asthenia, the younger 
the child and more feeble the constitution, the greater the danger. 

Unfavorable symptoms are a pulse becoming more and more frequent 
and feeble, pallor of countenance, inability of the patient to support the 
head, total loss of appetite, refusal to notice or be amused by playthings, 
absence of tears when crying — a symptom which the French writers have 
pointed out — and the appearance of pemphigus on the face or elsewhere. 

Indications on which a favorable prognosis may be based are moderate 
acceleration of pulse, pneumonitis primary and limited to one side, ability 
to support the head or sit erect, being amused by playthings, etc. 

Treatment. — The treatment of the two forms of pneumonitis, namely, 
catarrhal and croupous, the former occurring chiefly under the age of 
three years, and being secondary, the latter occurring in most patients 
over that age, require to be considered separately as much as do their 
symptoms and anatomical characters. 

. Catarrhal pneumonitis when developed from and upon a bronchitis, as 
it so often is, requires for the most part the continuance of the remedies 
which, are appropriate for the primary disease. (See Art. Bronchitis.) 
But from the fact that it is secondary, and in children of a tender age, 
and sin.ce the danger as regards the pneumonitis is due to asthenia, more 
actively sustaining measures are demanded than might be required for 
the uncomplicated bronchitis. When the pneumonitis has continued a 
few days, and often in its commencement, carbonate of ammonia and 
alcoholic stimulants are needed, and the diet from the first should be 
nutritious. An opiate, as the compound tincture of ipecacuanha, should 
be, added to the cough-mixture, if there is restlessness or insufficient sleep, 
and the external treatment recommended for bronchitis should be con- 
tinued. In that form of catarrhal pneumonitis which is due to passive 
^congestion .or hypostasis, in the causation of which debility is an important 



TREATMENT. 547 

factor, tonic and stimulating measures are still more imperatively required. 
Frequent change of position is useful in such cases. 

In Croupous pneumonitis, if seen at the commencement or within a few 
hours of the commencement, an emetic of ipecacuanha may be given, as 
recommended by Trousseau. This acts promptly as a cardiac sedative 
diminishing somewhat the afflux of blood to the lungs, and moderating 
the inflammation. It should not be employed except at the period men- 
tioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, as it is too 
depressing. But while the application of leeches in catarrhal pneumonitis 
is very rarely admissible, on account of the tender age of the patient and 
the secondary character of the inflammation, they may be useful in robust 
children with croupous pneumonitis, if applied sufficiently early, namely, 
within the first twelve hours. Two leeches are sufficient for a child of five 
years. When solidification of the lung has occurred, the time for the ab- 
straction of blood is past. But we have in aconite and veratrum viride 
efficient substitutes for bloodletting, which, by their sedative effect on the 
heart, diminish the exaggerated afflux of blood to the inflamed lung, and 
thus enable us to meet the indication of treatment in the first stage of the 
inflammation. It is important in all severe cases to preserve the blood 
and the strength, for the danger in the end is chiefly from asthenia. 
Aconite as a cardiac sedative in the treatment of children is safer than 
veratrum viride ; it is not necessary to watch its effects so carefully. 

The following Avill be found a useful formula for a child of five years : — 

R. Tinct. ipecac, comp. (Squibb's), gtt. xvi.-xxiv ; 
Tinct. rad. aconite, gtt. xvj ; 
Syr. bal. tolut. ; 
Aquae, aa %]. 
Dose, one teaspoonful every three hours ; or the aconite may be given alone, 
dropped in sweetened water or syrup of tolu. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage ; in other words, if it appear from the 
signs that the inflamed lobe or lobes are hepatized, little benefit accrues 
from the farther use of aconite or veratrum viride, and harm may result. 
In this stage the above prescription, with the aconite omitted, may be 
continued, or the following may be employed : — 

R. Morpli. sulphat., gr. j ; 
Syr. ipecacuanhse, ^j ; 
Syr. bal. tolut., §iij. Misce. 
Dose, one teaspoonful every three hours to a child of five years. 

The remarks made in reference to the use of quinia and digitalis for 
bronchitis apply with still more force to their use in both the catarrhal and 



548 PNEUMONITIS. 

croupous forms of pneumonitis. In secondary pneumonitis and primary 
occurring in feeble children these agents are in many instances preferable 
to any other medicine for the purpose of reducing the temperature and 
pulse, since they produce this result without depression. They may be 
administered in these cases from the first day, and their use may obviously 
be continued longer than would be safe for aconite or veratrum viride. 

When the inflammation begins to abate there is usually progressive 
improvement. Many now recover with simple mucilaginous drinks or 
mild expectorants for the accompanying bronchitis, as syrup of ipecacu- 
anha or squills in small doses. Others require more sustaining measures, 
and for such carbonate of ammonia is preferable with, perhaps, quinia. 
In severe pneumonitis it is of the utmost importance to sustain the 
vital powers, even from the commencement of the inflammation. There 
can be no doubt that the great error in the therapeutic management of 
children with this malady has been the employment of medicines which 
reduce the strength when gentler measures or those of a sustaining nature 
were required. Alcoholic stimulants are required sooner or later in most 
cases, at an early period in feeble children and in secondary forms of the 
inflammation. Infants may take three or four drops of Bourbon whisky 
or brandy for each month of their age every two or three hours. The 
diet should be nutritious, consisting of milk, animal broths, and the like, 
unless during the first three or four days in robust children. 

The bowels should be kept open, as an important part of the treatment 
of croupous pneumonitis in its first stages. A small dose of castor oil, 
Rochelle salts, or citrate of magnesia should be given if there is any ten- 
dency to constipation, and repeated from time to time if required. A 
saline aperient by its derivative and refrigerant effect in some cases obvi- 
ates the necessity of employing cardiac sedatives. 

Local treatment is required in all cases ; counter irritation should be 
produced as soon as possible over the inflamed lobe, by mustard, iodine, 
or some stimulating liniment, and, except at the time of this application, 
the chest should be constantly covered with an emollient poultice, or with 
a cloth wrung out of warm water and covered with oil-silk. I prefer, 
however, the constant application, under the oil-silk, of the following 
poultice, made large but as thin as the cover of a book, and therefore 
light : — 

R. Pulv. sinapis., §ss ; 

Pulv. semin. lini, §viij. Misce. 

In a large proportion of cases vesication is not required. If the inflam- 
mation is extensive, and the symptoms urgent, it is occasionally advisable 
to blister, and the cantharidal collodion should be used for this purpose. 
A safe, almost painless, and at the same time efficient, mode of applying 
this is in spots as large as a ten-cent piece, half a dozen, more or fewer 



PLEURITIS. 549 

according to the extent of the inflammation, the skin of course remaining 
sound between them. This mode of application obviates the danger of 
producing a troublesome sore, which sometimes occurs in children from 
the ordinary mode of vesication. 

In cheesy pneumonitis, which is always accompanied by anaemia, and 
great reduction of the vital powers, carbonate of ammonia with citrate of 
iron and ammonia equal parts, or cod-liver oil administered three times 
daily with two drops or more of syrup of iodide of iron, will be found use- 
ful, as is also quinine with iron. The patients require the most nutritious 
diet and alcoholic stimulants. In the local treatment of this form of in- 
flammation vesication, even so mild as that by cantharidal collodion, 
should be avoided. 



CHAPTER VII. 

PLEURITIS. 

Pleuritis occurs in children, as in adults, both as a primary and 
secondary disease. Secondary pleuritis, or pleuritis occurring during the 
course of other disease*, and due to those diseases, is common in infancy 
and childhood, as it is at other ages. Idiopathic pleuritis was formerly 
believed to be very rare in children under the age of five years, though 
not infrequent in those above that age. But greater precision in the ex- 
amination of cases, more accurate means of diagnosis, more knowledge of 
the nature of diseases, and more frequent autopsies have enabled the pro- 
fession of the present time to correct this as well as many other errors, 
and we now know that primary pleuritis is not very infrequent in young 
children, even in infants. There can be no doubt that many cases of this 
malady in young children have been, and even now are mistaken by good 
practitioners for other diseases, especially for pneumonitis, or if the pleuritis 
is to a certain extent latent, have been mistaken for remittent or malarious 
fever, or the fever due to dentition or intestinal irritation. I have records 
of several cases occurring both in family and hospital practice, in which 
young children perished with a wrong diagnosis or without a diagnosis, 
when the post-mortem examination revealed a pleuritis often of long stand- 
ing. Thus, in one case of fatal empyema commencing at the age of six 
months and continuing several months, chronic pneumonitis had been 
diagnosticated by a physician well known to be thorough in his examina- 
tions and usually accurate. In another case, which proved fatal at about 
the age of one year, the child, who lived in a malarial locality, had been 



550 PLEURITIS. 

for weeks under treatment for supposed malarial disease, but in this case 
diagnosis was easy with a proper examination, for at my first visit, which 
was when the child was dying, there was decided dulness on percussion 
over the posterior portion of the right side of the chest. In this case the 
right lung was adherent to the ribs anteriorly and laterally, while pos- 
teriorly it was separated by pus which crowded forward this organ so 
that its posterior surface was concave. 

The following statistics probably show about the average frequency of 
primary pleuritis in young children. Of 404 children under the age of 
twelve years, whom I treated in private practice during the months im- 
mediately preceding May, 1874, two under the age of three years had 
primary pleuritis, or one-half per cent. A recital of these cases will be 
permitted, as their histories and physical signs show how liable the prac- 
titioner may be to a wrong diagnosis, in similar cases, if he do not take 
time to make full and exact examinations. One of the children was a 
girl aged two and a half years, whose previous health had been good. On 
April 2d she was suddenly taken sick with active febrile movement. Her 
pulse was 'about 180 per minute, counted with difficulty on account of the 
fretfulness, and the respiration was 88, and accompanied by an expiratory 
moan. At first no marked physical signs were observed in the chest, but 
within a few days a distinct clicking pleuritic sound was observed in the 
left infra-scapular region, and later still a creaking sound in the same 
place, during respiration. No perceptible difference was observed in the 
percussion-sound upon the two sides of the chest. The febrile movement 
continued nearly a month when it gradually abated, and the health of the 
patient was fully restored. The temperature on five of the six days, from 
April 18th to 24th, was 102°, 103°, 100^°, 99^°, and 102°, and the pulse 
on two of these days was recorded at 136 and 140. This child was ex- 
amined by one of the most accurate auscultators in New York, who believed 
that there was almost no exudation of serum in the chest but an exudation 
of fibrin of little thickness. The second case was an infant aged eighteen 
months, who for six weeks had had an expiratory moan with febrile move- 
ment. The parents stated that his general health previously to his present 
sickness had been good, but the family were destitute, and his system had 
probably been in a more or less cachectic state from bad regimen. This 
child when first visited was feeble and wasted, as if from tubercular dis- 
ease. The percussion- sound was flat over the lower half of the right side 
of the chest. A few drops of pus were withdrawn from the pleural cavity 
by the hypodermic syringe introduced a little below the angle of the 
scapula, and then the diagnosis being established, ^iij to Jiv of very thick 
pus were removed by the aspirator when it ceased to flow. The respira- 
tion afterwards was less painful and the child slowly but progressively 
convalesced. There was in this as in the preceding case no appreciable 



CAUSES. 551 

bulging of the intercostal spaces, and no difference in the dimensions of 
the two sides. 

In hospital and dispensary practice the proportion of cases of primary 
pleurisies is in my opinion somewhat larger than in private practice, since 
the cachexia so common in children in these institutions is, as we will see, 
one of the predisposing causes of this form of inflammation. The frequency 
of secondary pleurisy varies in different years or seasons, according to the 
prevalence of the maladies on which it depends. Thus during extensive 
epidemics of scarlet fever, pleuritis is more frequent than at other times. 

Cause The ordinary cause of primary pleuritis is the same as that of 

most other primary inflammations, to wit, the impression of cold. This 
malady is, therefore, most common in the cool months, and in times of 
changeable temperature. Feebleness of constitution is an acknowledged 
predisposing cause in children. Therefore, children whose blood is im- 
poverished by anti-hygienic influences to which they are exposed, or by 
previous disease, are more liable to pleuritis than those who possess a sound 
constitution. Hence the fact that a larger proportion of cases occur among 
foundlings and the children of the city poor, than among those who are 
well nourished, and live in comfortable circumstances. 

It is probably due to both the causes now mentioned, namely, careless 
exposure by nurses to cold or to currents of air on the one hand, and 
cachexia on the other, that pleuritis is common in newborn infants in 
foundling asylums. Cases like the following are not infrequent. In 1867 
I made the post-mortem examination of a foundling who died in the New 
York Infant Asylum. Its age was about one month. A small amount 
of pus, not more than one drachm, was found in one pleural cavity, and 
less than this quantity in the other. On both sides there was nearly gen- 
eral injection of costal and pulmonary pleura, but with little or no sero- 
fibrinous exudation. There was also pus at the root of each lung, extending 
somewhat over the lung, but under the pleura. The fact of a double pleu- 
ritis without pulmonary disease indicated a constitutional cause, but there 
was no apparent cause of this nature, apart from the impoverishment of 
the blood. 

Billard, whose observations were made among foundlings in the Hospice 
des Enfants Trouves, says : " Pleurisy is more common among young in- 
fants than is generally supposed ; it often appears without the lungs par- 
ticipating in the inflammation. I have seen several infants die immediately 
after birth from this affection." He relates two cases of double idiopathic 
pleuritis ending fatally at the ages of two and ten days. (Disease of In- 
fants, page 419.) Mignot, whose observations were made in the same in- 
stitution, also records ten pleurisies, five of which were idiopathic, in one 
hundred and nineteen necropsies of newborn infants. (Maladies pendant 
la Premier Age.) 

The chief causes of secondary pleuritis are tubercles, pneumonitis, scarlet 



552 PLEURITIS. 

fever, and the entrance of some morbid product as pus into the pleural 
cavity. Tubercles situated under the pleura are, as is well known, a com- 
mon cause of this inflammation at any age, but pleuritis is less frequent in 
the tuberculosis of children than of adults. This difference is due to the 
fact that tubercles in children, especially in young children, are ordinarily 
small, and disseminated in various organs through the system, so as to 
produce comparatively little inflammation and destruction of the contigu- 
ous tissues before the fatal ending. 

A similar difference exists in regard to the frequency of pleuritis as a re- 
sult of pneumonitis in the two periods. Croupous pneumonia, which is the 
common form of pulmonary inflammation in adults, ordinarily involves 
the pleura, as is well known. On the other hand, catarrhal pneumonia, 
which is the form of inflammation, common in childhood, commonly occurs 
without exciting a pleuritis. 

One of the exanthematic fevers, namely, scarlatina, not infrequently also 
produces pleuritis, occurring either as a complication or sequel. This re- 
sult appears to be sometimes due to the altered state of the blood resulting 
from the presence of the scarlatinous virus. In other instances it is prob- 
ably the result of the retained urea consequent on scarlatinous nephritis, 
for pleuritis is a common complication of Bright's disease. 

In young children pleuritis is sometimes due to the discharge into the 
pleural cavity of some morbid product, as pus, softened tubercle, or decom- 
posed lung-tissue, which from its very irritating effect produces a fatal in- 
flammation. I have preserved the records of several such cases, which I 
have observed. 

A retropharyngeal abscess, descending behind the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity. A sup- 
purated bronchial gland or abscess in the walls of the chest occasionally 
produces the same result. In January, 1864, 1 presented to the New York 
Pathological Society the lungs of an infant, with the following history : 
R., aged 9 months, of strumous parentage, and whose only sister had suf- 
fered severely from strumous ophthalmia and periostitis, was taken sick 
about December 19, 1863, with febrile movement, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d, the 
mother called my attention to a prominence just below the right clavicle. 
This proved to be an abscess. A poultice was applied, in the expectation 
that it would discharge externally. On the 24th of December, however, 
the prominence subsided, and immediately the symptoms were greatly ag- 
gravated. The pulse rose to 160 per minute, the respiration to 60 or 80, 
and expiration was accompanied by a moan, so common in acute inflam- 
mation of the pleura or lung. Within a day or two after the disappear- 
ance of the tumor, and the exacerbation of the symptoms, dulness on per- 
cussion was observed on this side, and this increased till there was perfect 
flatness. The right pleural cavity had evidently filled with liquid, the 



causes. 553 

acceleration of pulse and respiration continued, the patient grew more and 
more feeble, and death occurred December 31st. 

At the autopsy, on dissecting away the integument from the right side 
of the chest, an abscess was opened, containing nearly an ounce of pus, 
located at the point where the tumor has been observed. There was a 
small round opening from this abscess directly into the cavity of the chest, 
so that, on depressing the ribs, liquid escaped from the cavity. On re- 
moving the sternum, the liquid was found to consist mainly of serum with 
lymph, and at the bottom of the liquid was considerable pus. I have met 
one other case, apparently almost identical with this, the infant being seven 
months old, but I did not attend it in the latter part of its sickness. The 
abscess in the case which I have detailed was obviously strumous, prob- 
ably occurring from glandular inflammation. This mode of production 
of pleuritis, namely, by the discharge of an abscess located in the thoracic 
walls, is no doubt rare. It was so considered by the members of the Path- 
ological Society. 

We occasionally meet cases, especially in foundling asylums, which have 
a different origin. An indolent pneumonitis occurs over a circumscribed 
area in the posterior part of the lung, whether it results from hypostasis, 
or from exposure to cold. A minute abscess, often not larger than a pin's 
head, or a small shot, occurs in the inflamed part. Perhaps this abscess 
is located in a bronchiole, and it may result from the muco-pus, which 
has collected in this tube, and was not expectorated on account of the low 
vitality and feeble functional activity of the tissues. The pus approaching 
the pleural surface, produces circumscribed pleuritis at that point, or open- 
ing into the pleural cavity, gives rise to general pleuritis. Often several 
of these abscesses are observed in the inflamed parenchyma. The follow- 
ing are cases in point : — 

Case 1 — I. M., male infant, was admitted into the Nursery and 
Child's Hospital, May 19, 1859, at the age of two months. He was very 
delicate at the time of admission, and had slight bronchitis, but, being 
placed with a wet-nurse, he gradually improved. About the middle of 
July, attacks of diarrhoea occurred, each lasting from one to two days, and 
from this time his health declined. Furuncular eruptions appeared on the 
head and neck, and, though sustaining measures were employed with medi- 
cines to control the diarrhoea, emaciation and feebleness gradually in- 
creased. 

The records on August 1st state, " Continues to fail, apparently from the 
attacks of diarrhoea; the furuncular eruption continues." On 3d of Au- 
gust, he died suddenly of apnoea, though there has been no symptoms to 
direct attention to the chest. Possibly he had a slight cough, which had 
escaped detection. 

Autopsy eight hours after death — Stomach and jejunum healthy ; mucous 
membrane lining the lower part of the ileum and the entire colon vascu- 
lar, and that of the colon considerably thickened ; mesenteric glands en- 
larged, and of a lighter color than in health ; right lung compressed by a 



554 FLEURITIS. 

sero- fibrinous exudation, so as to occupy a small space, though the amount 
of liquid was not more than two ounces ; nearly the entire pleura, visceral 
and parietal, on this side, was covered with a fibrinous deposit of a creamy 
appearance. Some of this had settled in the depending portion of the 
cavity. This lung could be inflated, except a little of the lower lobe, 
which was hepatized. 

On the left side, the lung also occupied a very small space, being col- 
lapsed ; the upper lobe could be readily inflated, when it had the elasticity 
of healthy lung ; the lower lobe had a healthy appearance, and could be 
inflated, except a portion in the posterior aspect, measuring, perhaps, an 
inch in diameter ; this was partially coated with lymph, and was found to 
contain two small abscesses, one closed, the other opening externally on 
the surface of the lung and internally into a bronchial tube. On attempt- 
ing inflation, the air passed directly through this opening. The closed 
abscess contained from one-third to half a drachm of pus- corpuscles, and 
disintegrated lung-tissue, as shown by the microscope. The child was 
much emaciated. 

Case 2 — M. I , female, was admitted into the Child's Hospital, 

October 7, 1859, at the age of about four months ; at the time of admis- 
sion was somewhat wasted with diarrhoea ; her health improved partially, 
but she remained feeble, and w r as at times much troubled with meteorism, 
which occasioned pain. 

On the 2d of November, she was suddenly seized with great dyspnoea, 
which terminated fatally in about a quarter of an hour. Previously to 
the dyspnoea, no cough had been noticed, or other symptoms referable to 
the chest. 

Autopsy — Body considerably emaciated ; left lung healthy, with the 
exception of slight hypostatic congestion ; right lung adherent to the dia- 
phragm, and to a considerable part of the costal pleura, by fibrinous exu- 
dation ; this lung was somewhat compressed and non-crepitant ; the upper 
lobe floated in water; the middle and lower sank and could not be inflated, 
or but slightly ; this portion of the lung contained a few small abscesses, 
filled with purulent matter, each holding scarcely more than one drop ; 
two of these seemed to have discharged into the pleural cavity, as the air 
passed through them in attempting to inflate, but possibly they may have 
been opened in separating the adhesions which united the two pleural sur- 
faces at this point : two or three ounces of fluid were contained in the 
pleural cavity, consisting, in addition to serum, of fibrinous flocculi, epi- 
thelial cells from the pleura, pus-cells, and compound granular cells ; the 
lower portion of this fluid, on standing, contained so much pus that it pre- 
sented the characteristic gelatinous appearance on the addition of liquor 
potassae ; the other organs generally were normal in appearance, but the 
liver was somewhat congested, and there was also decided hyperoemia of 
the mucous membrane of the colon near the ileo-caecal valve, and in the 
descending portion. 

Anatomical Characters The first appreciable structural change 

which occurs in pleuritis is engorgement of the vessels lying underneath 
the pleura. There can be seen, if an opportunity is presented, as in the 
case detailed above, a network of engorged capillaries. Immediately exu- 
dation commences into the connective tissue surrounding the capillaries, 



ANATOMICAL CHARACTERS. 555 

the pleura becomes dry and lustreless, and loses its epithelial covering, and 
soon the liquor sanguinis begins to exude through it. The amount of 
serum and fibrin which escapes into the pleural cavity varies greatly in 
different cases, as does their relative proportion. 

In pleuritis due to the irritation of tubercles, or to extension of inflam- 
mation from an inflamed lung to the pleura which covers it, the amount 
of liquid exudation is ordinarily small, and occasionally almost entirely 
absent, so that the visceral and costal surfaces remain in contact. In other 
cases, namely, when the pleuritis is idiopathic, or due to uraemia, or to a 
foreign substance in the pleural cavity, the liquid effusion is considerable, 
producing more or less compression of the lung. There are, however, ex- 
ceptions to this general statement. In idiopathic pleuritis the exudation 
may consist almost entirely of fibrin, and be scanty, as in the case related 
above. On the other hand, I have seen a considerable exudation of serum 
with fibrin and pus in tubercular pleuritis, so as to compress considerably 
the lung. 

If the lung is not too firmly attached by the fibrin to the walls of the 
chest, the liquid which is exuded presses it inward towards its root or its 
point of attachment to the mediastinum. If the quantity of liquid is large 
the compression may totally exclude air from the lung, and it becomes 
like a fleshy mass, or is carnijied. 

Ordinarily the fibrin forms a layer over the inflamed pleura, at first soft 
and readily detached, but gradually becoming firmer, and shreds or floc- 
culi of fibrin, becoming separated, float in the exuded serum. When the 
inflammation has continued a short time, granulations appear on the in- 
flamed surface, receiving their supply of blood from the subpleural capil- 
laries, which have been prolonged. These granulations, when the serum 
is absorbed, uniting with those on the opposite side, form permanent ad- 
hesions. 

Pleuritis, except when due to a local cause seated beneath the pleura, 
as tubercle or pneumonitis, extends rapidly, soon becoming general. 

In a certain proportion of cases empyema occurs. The proportion of 
pleurisies in feeble and ill-conditioned infants which are or which become 
suppurative is very large. Hence empyema, as I have often noticed, is 
not infrequent in the institutions of this city where such infants are treated. 
Secondary pleuritis is more apt to be suppurative than is the primary in- 
flammation. The pleuritis complicating or following scarlatina is usually 
so, being, therefore, often more dangerous than the primary disease. 

Pleuritis has, for convenience of description, been divided into three 
stages : the first, extending from the commencement of the inflammation 
to the time when there is an appreciable amount of exudation ; the second, 
from the time that the exudation is appreciable to the commencement of 
absorption ; the third stage is that of absorption or convalescence. Ab- 
sorption commences when the inflammation abates, and the rapidity with 



556 PLEURITIS. 

which the fluid disappears varies greatly in different cases. As absorp- 
tion occurs, the compressed lung gradually expands to occupy the place 
of the fluid. Sometimes absorption occurs more rapidly than the expan- 
sion, so that there is depression for a time of the thorax on the affected 
side, which gradually disappears. The serum is first absorbed, and then 
the fibrin, undergoing fatty degeneration and liquefaction, is also ab- 
sorbed. Occasionally portions of the fibrin instead of being absorbed 
undergo calcification, after which there is no further change. Commonly, 
as the serum is removed, the two pleural surfaces become permanently 
adherent, as has been already stated, and the lobes are likewise united to 
each other. 

In rare instances, in which there is a large amount of serous exudation, 
producing complete carnification of the lung, and absorption is slow, infla- 
tion never occurs, and the ribs of the affected side are permanently 
depressed. Respiration henceforth is performed entirely by the other 
lung, which increases somewhat in volume by hypertrophy of the air-cells. 
The compressed lung remains noncrepitant and firm, and its color some- 
what lighter than the natural hue, from defective supply of blood and 
granular change in its anatomical elements. 

In empyema, the patient cannot recover by absorption of the pus unless 
its quantity is small. If the quantity is small or moderate the liquor 
puris is first absorbed, and the pus-cells, becoming fatty and then liquefy- 
ing, may also be absorbed and the patient recover. Indeed, in all cases 
of pleuritis, pus-cells may be detected in the exudation by the microscope. 
But if the pus predominates, or is in such quantity as to be apparent to 
the naked eye, recovery is slow and uncertain, and usually impossible by 
absorption. Empyema is, therefore, except when relieved by thoracen- 
tesis, commonly a lingering disease, attended by many of the symptoms of 
tuberculosis. Spontaneous cure occasionally occurs by discharge of pus 
into a bronchial tube, or externally through the walls of the chest. I 
have witnessed both these modes of termination. In certain instances, 
pleuritis on the left side becomes complicated with pericarditis, and, more 
rarely, pleuritis in the lower part of the right pleural cavity with peri- 
hepatitis, the inflammation extending in the one case through the pericar- 
dium, in the other through the diaphragm. I have met four cases of the 
former complication, and one of the latter in infants. 

Symptoms The commencement of pleuritis is, in most instances, 

abrupt. Sometimes we observe a rigor or chilliness as the initial symp- 
tom, but this is in many cases not observed. An active febrile movement 
is suddenly developed, attended by headache, and perhaps vomiting. 
Sometimes the child screams violently at short intervals, as if from enter- 
algia or other severe pain. There is, usually, at this early stage, little or 
no cough, or other symptom characteristic of disease located in the chest. 
The symptoms of pleuritis obviously vary considerably in different cases, 



SYMPTOMS. 557 

according to the presence or absence of other diseases, the age and robust- 
ness of the patient, and the extent of the inflammation. 

In acute primary pleuritis the pulse rises to 130 or 140 beats per minute, 
and in young children it is often more frequent, numbering 160 or 180. 
The frequency of the respiration is increased in a corresponding degree, 
and is accompanied by the expiratory moan. The temperature is probably 
at 102° or 103°. The face is more or less flushed and indicative of suffer- 
ing. The child, if old enough to speak, complains of a stitchlike pain in 
the chest, which is most intense on inspiration and in coughing. Occa- 
sionally we can detect tenderness on pressing or percussing over the affected 
side. Sometimes the patient refers the pain to the epigastric region, on 
account of the distribution of some of the fibres of the intercostal nerves 
in this region. He assumes a certain position, as the erect, semi-recum- 
bent, or the recumbent on one side, in which there is comparative ease of 
respiration, and his suffering is less. If disturbed or removed from this 
position he is fretful, his cough is more frequent, and the respiration is 
more painful. The cough is short, dry, or hacking, unless bronchitis 
coexist, in which case there is more or less expectoration. At the same 
time those symptoms are present which are common in all inflammatory 
affections, such as anorexia and thirst. 

After some days the symptoms partially abate. The pulse and respira- 
tion are less frequent, though still accelerated, and the latter is less painful. 
Convalescence is more protracted in pleuritis than in ordinary pneumonitis. 
Several weeks frequently elapse before the liquid is fully absorbed, during 
which time there is apt to be more or less acceleration of pulse and eleva- 
tion of temperature. Certain writers state a much shorter duration of the 
febrile movement, but in the cases which 1 have observed, which seemed 
to be most nearly typical, I think that the temperature did not fall to the 
normal standard before the close of the third week, or even later. The 
appetite and strength returned gradually. 

The symptoms of pleuritis, though commonly so pronounced as to direct 
attention at once to the chest as the seat of the disease, have in other 
instances such mildness that the location of the inflammation in the thorax 
can only be ascertained by a careful examination of symptoms and physical 
signs. There is, indeed, every degree between severe and conspicuous 
symptoms, such as I have described, and latency. 

Both primary and secondary pleurisies may be latent, latency being 
more frequent in infancy than childhood. The following is a not unusual 
example : A feeble infant, aged five months and twenty-eight days, died 
suddenly at the Nursery and Child's Hospital in December, 1870. The 
attention of the resident physician had not been called to it, as it was not 
supposed to be sick, although its general condition was bad, and the nurse 
who had charge of the ward stated that it had presented no symptom of 
disease, unless possibly a slight cough during the last three or four days. 



558 PLEUEITIS. 

Percussion over the right side of the chest of the corpse gave a flat reso- 
nance, and the right lung was found at the autopsy carnified, and covered 
with a loose, fibrinous layer, three-fourths of an inch thick in places, with 
but a scanty exudation of serum. 

In empyema the symptoms may not differ materially at first from those 
in the ordinary form of pleuritis, but absorption occurs of only a portion 
of the liquor puris. The pus produces the ordinary effects of purulent 
collections in the system, namely, loss of appetite, hectic fever, emacia- 
tion, loss of strength. No improvement occurs except by discharge of 
pus, either by thoracentesis or through an ulcerative opening, after which 
the child usually slowly, but progressively, recovers. In fatal cases of 
empyema the vital powers gradually yield, the pulse becomes more fre- 
quent and feeble, the face and limbs pallid and cool, and death occurs 
from asthenia. 

Physical Signs Skilful auscultators disagree, or are in doubt, in 

regard to the nature of certain of the abnormal sounds heard in the chest 
in cases of pleurisy. And this disagreement or uncertainty is greater in 
the examination of children than of adults ; for in children, especially 
infants, many of the physical signs present peculiarities, so that they are 
less readily recognized or identified than in those who are older. Still, it 
is seldom difficult to make an accurate diagnosis by means of the physical 
signs even in the youngest child. 

Auscultation. — In the very commencement of the inflammation aus- 
cultation affords but little information. Probably we only notice that 
change in the vesicular respiration which necessarily results from the hur- 
ried breathing. A little later we observe (but this is only noticed in cer- 
tain cases, or when the visit is made at the proper moment), a dry rubbing 
sound at the seat of inflammation, which may be imitated by pushing the 
finger firmly across the dry palm of the hand. As the surface of the pleura 
becomes moistened by exudation this sound disappears. Next we observe, 
and this, too, only in certain cases, a moist friction-sound, heard near the 
surface of the chest. It may resemble closely the crepitant rale, for which 
it is sometimes mistaken, being a succession of fine friction-sounds. In 
other cases only one or two of these sounds are observed in each respira- 
tion, and they are well described by the term clicking. This crepitant, or 
clicking sound, may be heard through a considerable portion of the time 
during which the pleuritis continues, provided that there is but little liquid 
exudation, and the surfaces roughened by moist fibrin remain in contact. 
In other cases it is only heard for a brief period, disappearing when the 
contact of the surfaces is prevented by the liquid. After absorption of the 
liquid this sound may reappear, and in some cases it is heard only in the 
third stage. 

It will be recollected that the explanation which Trousseau gives of the 
occurrence of this sound differs from that which is commonly accepted. 



AUSCULTATION. 559 

" This sound," says he, " which is met with in the great majority of cases 
of pleurisy is, in fact, a crepitant rale, and I have called it the crepitant 
rale of pleurisy. My interpretation of it is very simple. Just as we never 
have erysipelas without engorgement of the cellular tissue, there cannot be 
erysipelas of the pleura or pleurisy, without an irritative engorgement of 
the subpleural cellular tissue, or of the peripheric pulmonary parenchyma. 
This fluxion naturally carries with it into the pulmonary vesicles a serous 
exudation analogous to that of pulmonary oedema. We also meet with a 
fine subcrepitant rale, which is very often heard quite at the beginning of 
the pleurisy, and which likewise nearly always continues for some weeks, 
when the fluid being absorbed, there only remains subinflammatory oedema 
of the more superficial parts of the lungs." Perhaps this explanation may 
apply to certain cases, but there can, I think, be no reasonable doubt that 
the clicking sound to which I have alluded, since it is superficial and does 
not commonly disappear after coughing, is in some instances pleuritic. 

When the second stage commences and the pleural cavity contains 
more or less liquid, the lung, unless adherent to the ribs, is carried inward 
and upward and compressed. The respiratory sound now disappears in 
children over the age of five years, but in a large proportion of cases in 
the first years of childhood, and usually in infancy, in which period the 
pleural cavity is small, respiration is heard when the ear is applied over 
the liquid. It is transmitted through the liquid from the bronchial tubes 
or from the opposite lung. Its character is bronchial, broncho-vesicular or 
vesicular. It varies in intensity according to the amount of the liquid, 
and the strength and rapidity of the respiration. When the inflammation 
is active, and exudation occurs rapidly, bronchial respiration may be heard 
as early as the second or third, or even on the first day, when the ear is 
applied in the scapular and infrascapular region. Rilliet and Barthez be- 
lieve that it differs from the bronchial respiration of pneumonia, not only 
in its duration, but also in the character of its sound, being metallic. If 
the inflammation is mild, and the exudation occurs slowly, bronchial respi- 
ration is not observed till after the lapse of some days. When there is a 
very considerable amount of liquid exudation, bronchial respiration may 
be observed in the infraclavicular region as it so often is in adult cases. 
-•Egophony is occasionally noticed in cases which are attended by a large 
effusion ; it coexists with the bronchial respiration. It is heard in the inter- 
and infrascapular spaces. Its duration is commonly brief, disappearing 
in three or four days, or even in less time. Feeble vesicular respiration may 
be heard in one part of the chest, while in other parts the bronchial respi- 
ration occurs, and in other parts still, namely, at the base, no sound what- 
ever is audible ; or, without the bronchial respiration, we may hear a dis- 
tant or faint vesicular murmur over the entire half of the chest, which is 
the seat of the disease. Such are the various combinations and modifica- 
tions of the respiratory sounds noticed in these cases, sounds which pre- 



560 PLEURITIS. 

sent variations in their presence and relative proportion as the disease 
advances. 

Percussion Percussion in the commencement of pleuritis before there 

is any appreciable exudation gives a negative result. If dulness is ob- 
served, it is due to coexisting disease, commonly pneumonitis or tubercu- 
losis. When exudation occurs, unless it is entirely fibrinous, percussion 
over the affected side gives at first a dull and then a flat sound, but above 
the level of the liquid the resonance is good, and occasionally tympanitic. 
The sensation communicated to the finger in percussing, is like that pro- 
duced by a solid substance. The flat percussion-sound distinguishes the 
pleuritic exudation from the solidification of pneumonitis, for the percus- 
sion-sound in pneumonitis is dull, but not flat. In young children, in 
whom pneumonitis is catarrhal, and limited to a part of a lobe, the differ- 
ence is very marked. Changes in the height of the flatness according 
to the position of the patient is sometimes observed in infancy and child- 
hood, but this sign is less reliable than in adult life. Now and then we 
observe cases in which other physical signs do not indicate the presence of 
a liquid in the pleural cavity, and there is no pulmonary disease, and yet 
percussion gives a dull sound. In these cases the dulness is due to the 
fibrinous exudation, which often has a very considerable thickness, espe- 
cially if its fibres are loosely arranged. I have related above a case in 
which the exudation was three-fourths of an inch thick. If the pleuritis 
depends upon tuberculosis or pneumonitis, the physical signs which charac- 
terize the primary disease are intensified by the exudation. 

Inspection — Mensuration At first, if respiration is painful the 

movements of the affected side in breathing are somewhat restrained, and 
subsequently when there is a large effusion they are more limited than on 
the opposite side. 

Bulging of the intercostal spaces, and distension of the thoracic walls 
from the fluid, are less frequently observed and less marked in young chil- 
dren than in adults. In the infant, especially if feeble, so readily are the 
lungs compressed, that incomplete carnification is apt to occur before the 
shape of the chest is materially altered. When there is a large pleuritic 
exudation with bulging of the intercostal spaces the circumference of the 
chest on the affected side is rarely more than three-fourths of an inch to 
one inch greater than that of the healthy side. 

On account of the peculiarities as regards the physical signs and the 
mechanical effect of a liquid in the pleural cavity of a young child, phy- 
sicians whose knowledge of pleuritic effusions is derived chiefly from the 
examination of adult cases are apt to err in diagnosis. Thus, in 1870, a 
carnified lung, covered with a thick pyogenic membrane from which gran- 
ulations had arisen, was presented by myself to the New York Pathologi- 
cal Society, with the following history of the case. W., twelve months old 
at the time of death, was taken sick at the age of six months, with fever, 



INSPECTION — MENSURATION. 56L 

and a cough, which was slight and not frequent. At about eight months 
he first came under observation. The infant was then small for its age, 
pallid and thin. The two sides of the chest measured the same, and on 
both sides the intercostal spaces were somewhat depressed, but percussion 
over the right side produced a flat sound, showing that the air was wholly 
excluded from the right lung. The respiration upon the affected side was 
bronchial and distinct. Two well-known physicians of this city, thorough 
in their examinations,, and usually accurate in diagnosis, examined this 
case in reference to the propriety of thoracentesis, and both expressed a 
decided opinion that the pathological state was not a pleuritis, but either 
collapse or interstitial pneumonitis, one of them observing, as he thought, 
in addition to the physical signs already stated, bronchophony. The febrile 
movement was moderate, and no decided hectic was observed. Death oc- 
curred from exhaustion. At the autopsy about half a pint of thick pus 
was found in the right pleural cavity, producing complete carnification of 
the lung. The pus, which, considering the stunted growth of the child and 
small size of the pleural cavity, was considerable, had evidently lost part 
of the liquor puris by absorption. 

The following case, which shows how deceptive the physical signs may 
be in young children in cases of suppurative pleuritis, will repay perusal, 
since the life of the patient depends in great part on a correct understand- 
ing of his condition, so that appropriate measures will be employed. 

Case. — H , boy, four years four months old, was taken with scarlet 

fever in the latter part of May, 1868. It was severe, and was attended 
with inflammation of the glands and connective tissue of the neck, with 
suppuration on both sides. Purulent discharges from the abscesses contin- 
ued through the month of June. The patient was gradually convalescing, 
when, about July 4th, pleuritis commenced on the left side, attended by 
the ordinary symptoms of acute forms of this inflammation. A few days 
subsequently the pleural cavity was ascertained by examination to be about 
half full of liquid. 

Towards the close of July anasarca commenced about the ankles and 
gradually extended upwards. It was limited to the lower extremities and 
to the abdominal walls, and by the middle of August became excessive. 
The thoracic walls and the upper extremities were somewhat emaciated, 
and the face was pallid and anxious. 

On the 7th of August a careful examination of the chest was made in 
reference to the propriety of thoracentesis. The intercostal spaces on the 
left side were not prominent, but rather depressed. Percussion over the 
lower third of the left pleural cavity elicited a flat sound, while above this 
the resonance was tympanitic. On account of the great restlessness of 
the patient, no useful information was derived from change of position. 
On auscultation distinct bronchial respiration was heard over nearly or 
quite the entire left side of the chest. The apex beat of the heart was on 
the right of the sternum. It was my opinion, as well as that of two other 
physicians, that the liquid was in process of absorption, and that the quan- 
tity present was not large. Thoracentesis did not, therefore, seem a proper 
measure. The aspirator was at this time little used. 
36 



562 PLEURITIS. 

The anasarca still limited to the lower extremities, and the abdominal 
walls continued to increase, and on the 25th of August, so great was the 
distension, that the skin broke in one or two places above the ankles. 
The mind remained clear, the kidneys were apparently not involved, and 
the appetite was pretty good. Death occurred August 27th. 

Sectio Cadaver — Head not examined ; abdominal and right pleural 
cavities contained no effusion, and were in their normal state, except that 
the latter cavity was somewhat encroached upon by the heart and medi- 
astinum ; a great amount of oedema in the lower extremities and in the 
abdominal walls ; abdominal walls towards the spine about three inches 
thick, in consequence of oedema; right lung of good size and presenting 
the ordinary appearance, except a greater amount than usual of hypostatic 
congestion ; about three pints of pus (laudable) in the left pleural cavity ; 
left lung completely carnified and lying against the vertebral column ; its 
size about that of an orange, and its surface covered with a dense layer of 
fibrin ; heart displaced, as already stated, to the right and a little down- 
ward, so as to compress and partially obstruct the circulation in the 
ascending vena cava ; this vessel contained a continuous, firm, and yellow 
fibrinous clot, nearly filling its calibre ; the femoral vein, examined on 
one side, was found to contain soft and dark clots. Compression of the 
cava opposite the heart and the formation of clots had evidently given 
rise to the anasarca. 

An important negative sign, as we will see, is the absence of bron- 
chophony and vocal fremitus over that portion of the chest where the 
liquid has accumulated. 

Occasionally physical signs, w T hich commonly indicate tuberculosis, are 
heard in children as well as adults on auscultating the chest which is the 
seat of a pleuritic attack. Attention has been called to this fact by Eilliet 
and Barthez, one of whom had diagnosticated tuberculosis from these 
signs, in a case which fully recovered, and afterwards by Trousseau, who 
says : " In cases of pleurisy we often meet with all the stethoscopic signs 

which belong to the third stage of tubercular phthisis Amphoric 

respiration, gurgling, and cavernous voice are sometimes so well marked, 
that it is impossible to avoid attributing them to the existence of cavities 
in the luugs." The occurrence of these signs, however, in uncomplicated 
pleuritis is rare, but it is necessary to be aware of their occasional occur- 
rence, in order that the diagnosis in cases in which they are observed be 
more careful and guarded. 

It has been said by certain writers that displacement of the heart and 
the subdiaphragmatic organs by large pleuritic effusions is less frequent 
and less in degree in children than in adults. However this may be, it is 
certain that displacement of the heart to the right is common in pleurisy 
of the left side, even when the quantity of liquid in the pleural cavity is 
moderate. I have found this fact very useful in diagnosis. 

Diagnosis This is in certain cases readily made, but in other instances 

is, as we have seen, attended with difficulty. Obscure or doubtful cases 
occur chiefly in infancy. Partial or circumscribed pleuritis, attended 



DIAGNOSIS. 563 

with little or no serous exudation, is more apt to be overlooked than other 
forms of the inflammation, but, as it is ordinarily due to grave disease 
of the lungs, which requires the chief treatment, its detection is not very- 
important. The points involved in its d'agnosis are acceleration of pulse 
and respiration, increase of temperature, expiratory moan, friction-sound, 
and tenderness on percussion. 

The diagnosis of acute general pleuritis in its commencement, before the 
stage of effusion, is attended with some difficulty. It is most likely to be 
mistaken for pneumonitis, since the prominent symptoms in the commence- 
ment of the two diseases are similar. There is, however, in pleuritis 
ordinarily greater acceleration of pulse and respiration, greater elevation 
of temperature, greater suffering, as indicated by the features, and a more 
decided expiratory moan. It will aid in the differential diagnosis, in 
children under the age of five years, to recollect that acute pneumonitis 
is in most instances preceded by bronchitis, which is not the case with 
acute pleuritis, except as a coincidence. 

Pleuritis with effusion could only be mistaken for pneumonitis or hydro- 
thorax. But the loss of resonance on percussion in cases of pleuritic effu- 
sion is much greater than when the lung is solidified from pneumonitis. 
The physical signs, which are involved in the differential diagnosis of 
these diseases in the adult, are important, also, for diagnosis in children, 
though, as we have seen, they are less constant and less reliable in young 
children than in adults. In children over the age of five years they are 
pretty uniformly present. The signs alluded to are bulging of the inter- 
costal spaces, expansion and subsequently retraction of the chest, evidence 
of change in the height of the fluid by change in the position of the 
body, no bronchophony and fremitus as in pneumonitis, etc. The absence 
of bronchophony and vocal fremitus, as evidence of a liquid in the pleural 
cavity, needs to be emphasized. These physical signs may be observed in 
pleurisy, even when there is considerable effusion, provided that the ex- 
amination is made over a point where the lung happens to be adherent to 
the ribs, but if it is made over the liquid they will not be observed. The 
presence or absence, therefore, of these signs aids materially in the diag- 
nosis between a liquid and solidification of the lung. Hydrothorax in 
the child commonly results from one of the eruptive fevers, especially 
scarlatina, and its immediate cause is nephritic congestion or inflamma- 
tion, or heart disease. Rarely it is due to obstruction in the pulmonary 
circulation, in consequence of enlarged bronchial glands. It is not, there- 
fore, preceded nor accompanied by symptoms of inflammation referable 
to the chest, as in cases of pleuritic effusion. 

Empyema may be diagnosticated from the fact that there is but little 
diminution in the amount of liquid after several weeks have elapsed, and 
from the febrile movement, loss of appetite, flesh, and strength, which 
attend all large purulent collections. 



564 PLEURITIS. 

Prognosis — Primary pleuritis, occurring in patients previously healthy, 
commonly ends favorably ; but it is a serious disease if the general health 
has been much impaired. The prognosis is more favorable if, as is com- 
monly the case with this form of pleurisy, the patient is over the age of 
three or four years. 

Secondary pleuritis is, on the other hand, a grave affection, but the 
prognosis depends greatly on the character of the primary malady, and 
also on the age. Pleurisy resulting from and coexisting with pneumonitis 
commonly ends in recovery even in quite young patients. Pleuritis arising 
from scarlet fever is apt to be suppurative, and is, therefore, a serious com- 
plication or sequel, but a considerable proportion affected with it recover 
under judicious treatment. The prognosis in tubercular pleuritis and 
pleuritis occurring from the escape of pus into the pleural cavity is obvi- 
ously unfavorable. 

Tubercular pleuritis may be temporarily relieved, but it is apt to return. 
Suppurative pleuritis, or empyema, is also an unfavorable form of inflam- 
mation, characterized by the chronicity and many of the symptoms of 
tuberculosis. It is in time fatal unless the pus is evacuated. On the 
escape of the pus, whether spontaneously or by thoracentesis, there is 
usually progressive and complete restoration to health. In case the pus 
is evacuated, the prognosis is better in children than in adults. 

Treatment The indications of treatment are, in the commencement 

of the inflammation, to diminish its intensity, and relieve pain ; at a later 
period to promote absorption, and sustain the vital powers. 

Pleuritis is one of the few inflammations in early life in which the ab- 
straction of blood may be proper. It may be stated as a rule, that loss of 
blood is not only not required, but is an injudicious measure in all secon- 
dary pleurisies, and in the primary form after exudation into the pleural 
cavity has occurred. It is a useful measure at the commencement of 
acute primary pleuritis occurring in a robust state of system. One or two 
leeches should be applied directly over the seat of the inflammation, and 
bleeding may be encouraged for two or three hours subsequently by the 
application of cloths wrung out of warm water. Unfortunately the physi- 
cian is, in many cases, not called at this early period ; or, if called, he 
fails to make the diagnosis till there are evidences of exudation. 

After bleeding has ceased, or in subacute and secondary pleurisies with- 
out the employment of leeches, a large rubefacient cataplasm should be 
applied over the affected side of the chest, and covered with oil-silk. A 
poultice consisting of one part of mustard and sixteen of flaxseed between 
two pieces of thin muslin and sufficiently wet answers the purpose. 
Moderate counter-irritation diminishes the pain, but vesication at this 
early period is injurious. A blister applied so near the seat of the in- 
flammation may increase the afflux of blood towards it, and aggravate the 
disease. 



TREATMENT. 565 

Robust patients over the age of three or four years, are benefited by the 
use of cardiac sedatives in the commencement of acute pleuritis. The 
tincture of aconite root should be given, but its effects should be watched, 
and it should be discontinued or given less frequently when the pulse is 
reduced to nearly the natural number, or when sufficient exudation has 
occurred to produce the ordinary physical signs of liquid in the chest. It 
should be given cautiously in secondary pleuritis. 

Opiates are required, as in other serous inflammations, according to the 
pain. Dover's powder, in doses of one to three grains, according to the 
age, may be given every two or three hours, or less frequently if the patient 
is inclined to sleep. 

The following is a favorite prescription with me for a child of three 
years : — 

&. Tinct. ipecac, cornp. 

(Squibb's liquid Dover's powder), gtt. xvj-xxiv ; 
Tinct. rad. aconit., gtt. viij ; 
Syr. bal. tolut., fij. Misce. 
Dose, one teaspoonful every two or three hours. 

Such is the treatment required in the first stage of acute primary pleu- 
ritis, or that preceding the effusion. Secondary pleuritis requires fewer 
and less depressing measures. The appropriate treatment, in a larger pro- 
portion of the cases of this form of the disease, consists in the use of an 
opiate, with rubefacient and emollient applications to the chest. Abstrac- 
tion of blood is not required in this form of pleuritis, but the aconite is 
sometimes useful for a few days. 

Pleurisies dependent on pulmonary disease, which are circumscribed 
and attended with little serous effusion, require no other therapeutic 
measures than those already mentioned. The judicious use of opiates, 
and rubefacient and emollient applications, suffice for their treatment. 

In the treatment of other forms of pleurisy, which are attended by more 
or less effusion of liquid into the pleural cavity, measures designed to re- 
move this liquid are required when the inflammation has abated, and 
antiphlogistics are no longer appropriate. 

Liquids in the great cavities are best eliminated by hydragogue cathar- 
tics and by diuretics. For children, however, already weakened by pleu- 
ritic inflammation, cathartics are usually too depressing. Xow and then 
a robust patient, over the age of five or six years, with pleuritic effusion, 
may be benefited by an occasional purgative dose of bitartrate of potassa, 
or by from one-twelfth to one-sixth of a grain of podophyllin. But such 
cases are exceptional. In a majority of children the loss of strength re- 
sulting from cathartics more than counterbalances the good result from the 
liquid evacuations which they produce. 

Diuretics, on the other hand, are efficient remedies, and upon them our 
chief reliance must be placed. 



566 PLEURITIS. 

The diuretics from which good results may be expected are digitalis with 
acetate of potash, and in certain cases iodide of potassium. In the adult 
I have observed rapid absorption of the liquid by the administration of 
from one to two drachms daily of the iodide, given in doses of ten grains, 
and a child can take a proportionate dose. Two to five grains, according 
to the age, may be given every three hours. At the same time it is ad- 
visable to restrict the drinks. 

At this stage of the disease counter-irritation is appropriate, either by 
rubefacients or vesicants. The preferable mode of blistering the child is, 
in my opinion, by cantharidal collodion applied as recommended in the 
treatment of pneumonitis. I prefer, however, instead of vesication, the 
application by friction two or three times daily of the unguent, iodinii com- 
positi of the Pharmacopoeia. 

In secondary pleuritis the diet should be nutritious, consisting largely 
of animal broths, through the whole period of the disease. 

In primary pleuritis nutritious diet should be allowed after exudation 
has occurred. In some cases, more frequently in secondary than primary 
pleuritis, stimulants are required. In protracted pleuritis, or pleuritis 
occurring in a debilitated patient, tonics, both vegetable and chalybeate, 
are often serviceable, sustaining the strength while the process of absorp- 
tion is going on. 

Occasionally the measures which have been recommended above to 
promote absorption of the liquid in the pleural cavity do not have the 
effect which is desired. If there is no sensible diminution in its amount, 
and if the general health of the patient begins to fail, the performance of 
thoracentesis should be considered. We may accomplish by surgery what 
we fail to do by therapeutic means. 

Thoracentesis is one of the oldest operations in surgery, having been 
practised by the school of Hippocrates, and being described in the writings 
of Galen, but till a recent period it was only performed in rare instances, 
and then hesitatingly as a last resort. " During the middle ages," says 
Trousseau, " it was discussed whether it were better to make the opening 
into the chest by steel or by fire, and the operation was rarely performed, 
except in surgical lesions." It was reserved for Trousseau, between 1843 
and 1847, to convince the profession, amid considerable opposition, not 
only of the safety, but of the urgent need of the performance of thoracen- 
tesis in cases not only of purulent exudations, but also in many cases of 
extensive serous or sero-fibrinous exudations into the pleural cavity By 
a series of cases he was able to show the great risk in deferring the opera- 
tion, when there is a large and increasing effusion which does not yield to 
remedial measures, for orthopnoea suddenly developed may carry off the 
patient. 

Except Trousseau, Dr. Bowditch, of Boston, has done more than any 
other physician to remove all existing prejudices against thoracentesis, and 



TREATMENT. 567 

bring it into vogue. His statistics, as they are the most numerous, are 
the most satisfactory and convincing yet published. Previously to 1870 
he had performed this operation " 250 times in 154 persons, without once 
seeing any evil, or even any very distressing symptoms resulting from it, 
while on the other hand it has saved a large number of lives, that must 
otherwise have been sacrificed." Statistics show that thoracentesis, for 
the removal of pleuritic effusions, results favorably in a larger proportion 
of cases in childhood than in adult life. In my own practice during the 
last five years, this operation has been performed upon seven children with 
empyema, the result, in all instances, of the operation being favorable, 
except in one, in which there were, no doubt, tubercles, while during the 
same time in at least two instances, I have observed children perish of 
empyema without the operation. 

One of the chief reasons why thoracentesis was formerly so seldom per- 
formed, was the dread of admitting air into the pleural cavity. It was 
thought that the contact of air with the pleura in cases of empyema caused 
a continuance or aggravation of the suppurative inflammation, effected 
decomposition of the pus, and gave rise to the formation of noxious gases 
within the chest, which increased the cachexia and depression of the 
patient. No doubt the contact of air tends to promote purulent decompo- 
sition, but if the pus is removed by the operation, as it should be, or if 
the opening remains fistulous, no harm results in a care of empyema from 
the admission of a moderate quantity of air, except so far as it prevents 
expansion of the lungs. Any possible ill effects from pus decomposition 
can certainly be prevented by washing out the pleural cavity with tepid 
water, to which a little carbolic acid is added. At the present time, I 
think, the profession generally agree that the entrance of a moderate 
amount of air into the pleural cavity in cases of empyema, does little or 
no harm, but there is a general apprehension that it may convert a sero- 
fibrinous into a suppurative pleuritis. The evil effects of the admission of 
air have evidently been misunderstood. Surgeons are not deterred from 
the removal of ovarian tumors by the fear of admitting air into the peri- 
toneal cavity, and why its admission into the pleural cavity has been and 
is so much dreaded, it is difficult to understand. In the London Lancet, 
January loth, 1831, the case is related of a man who suffered from heart 
disease, and was led to think that the pressure of a small quantity of air 
internally might be substituted for external pressure, which always gave 
relief. The idea occurred to himself, and he was his own operator. He 
employed a fine tube about as slender as a common pin, to which a blad- 
der was attached containing common air. The point of this was thrust 
through the skin and subcutaneous tissues till it reached the cavity, and 
air was squeezed through it by compressing the bladder. Relief always 
followed, and improvement was effected in the patient's health. These 
experiments were continued two or three years. Dr. Lizars, who was 



568 PLEURITIS. 

present at the meeting of the medical society before which this case was 
related, stated that he had performed this operation on four or five patients 
affected with aneurisms, with some apparent benefit, and in no case with 
injury. 

In view of such facts it seems probable that the admission of a little air 
into the pleural cavity during the operation of thoracentesis can do little 
harm, whether the exudation, for the removal of which the operation is 
performed, is sero-fibrinous or purulent. However, with the mode of ope- 
rating which is now commonly employed, namely, by the aspirator, the 
admission of air is prevented. It is probable, also, that some of the pre- 
judice against thoracentesis resulted from the improper manner in which 
the operation was performed, with the faulty instruments employed previ- 
ously to the last thirty or thirty-five years. Surgeons previously to this 
time advised puncturing in the anterior aspect of the chest, instead of in 
the well-known eligible point, under the angle of the scapula. 

It is very important to be able to determine the circumstances under 
which thoracentesis should be performed. Dr. Anstie, in his article on 
pleurisy, in Reynolds' 's System of Medicine, lays down the following ju- 
dicious rules for determining when to operate : — 

1. "In all cases of pleurisy, at whatever date, where fluid is so copious 
as to fill one pleura, and begins to compress the lung of the other side ; for 
in all such cases there is the possibility of sudden and fatal orthopnoea. 

2. "In all cases of double pleurisy, when the total fluid may be said 
to occupy a space equal to half the united dimensions of the two pleural 
cavities. 

3. " In all cases where the effusion being large, there have been one or 
more fits of orthopnoea. 

4. "In all cases where the contained fluid can be suspected to be pus, an 
exploratory puncture must be made ; if purulent the fluid must be let out. 

5. " In all cases where a pleuritic effusion, occupying as much as half 
of one pleural cavity, has existed so long as one month, and shows no sign 
of progressive absorption." 

The simplicity and almost painlessness of the operation is an argument 
in favor of its early performance, even in certain cases which might and 
probably would eventuate favorably with only medicinal measures, for the 
evacuation of the liquid will often greatly shorten the disease, and relieve 
the patient of much suffering. American physicians have not yet learned 
to operate as early as some of our transatlantic brethren, and there is no 
doubt more danger of our deferring the operation too long, than of ope- 
rating at too early a period. Murchison tapped the chest of a boy, aged 
seven years, on the twelfth day of acute pleuritis, removing twenty-four 
ounces of nearly transparent serum, with the entrance of some air into 
the pleural cavity. The effusion had displaced the heart, and caused 



TREATMENT. 569 

slight dyspnoea and weakness of pulse. The patient did well, and in one 
month fully recovered. 

If the exudation is purulent, unless the quantity is very small, the physi- 
cian is indeed censurable if he defers tapping, for there is every proba- 
bility that the state of the child will become daily worse, from the in- 
creasing cachexia, and the retention of pus in the system endangers the 
formation of tubercles. (Art. Tuberculosis.) Cases like the following, 
which perhaps an early resort to tapping might relieve, are not in my 
opinion very infrequent. In the latter part of November, 1873, I was 
asked to see an infant, aged 12^ months, who had pleuritis of the right 
side, commencing a few days previously. During December the tempera- 
ture was usually from 101° to 101 1°, and pulse from 140 to 160 per min- 
ute. The physical signs indicated a small amount of liquid, no doubt 
purulent, in the inferior and posterior part of the right pleural cavity, and 
adhesion of the right lung laterally and anteriorly to the walls of the 
chest. The amount of liquid seemed so small, that it was deemed best, in 
consultation, to defer the operation, although there was progressive loss of 
flesh and strength. A few weeks subsequently, the symptoms and physi- 
cal signs indicated the formation of tubercles, and early in the following 
spring death occurred. 

On the other hand we sometimes meet cases in which there is consider- 
able liquid effusion, with but little dyspnoea, loss of appetite, and consti- 
tutional disturbance. Under such circumstances, the general condition 
being good, thoracentesis may ordinarily be safely deferred. Medicinal 
agents may, and probably will, suffice for the cure. 

The point for the puncture may be ascertained by the rules of Dr. Bow- 
ditch : " Find the inferior limit of the sound lung behind, and tap two 
inches higher than this on the pleuritic side, at a point in a line let fall 
perpendicularly from the angle of the scapula. Push in the intercostal 
space here with the point of the finger, and plunge the trocar quickly in 
at the depressed part ; be sure to puncture rapidly and to a sufficient depth, 
or you may be balked by the false membrane occluding the canula." An 
eligible point for the operation is from one to two inches below the angle 
of the scapula, either upon the line drawn vertically through that angle 
or a little inside or outside of that line. 

Having selected the point for the puncture, the hypodermic syringe 
should be introduced, and by slowly withdrawing the piston, we are able 
to ascertain the nature of the liquid, for even if it be very thick pus, a few 
drops will enter the instrument. If it be mainly serous, and we desire to 
remove it, it may be allowed to drip from the instrument, or it may be 
removed through the small point of the aspirator. If it be pus, it can be 
removed by employing the medium-sized point of the aspirator, or by es- 
tablishing a fistulous opening, with a narrow bistoury introduced close to 
the upper edge of the rib, the skin being drawn up a little with the finger. 



570 PLEURITIS. 

By either operation children ordinarily do well, though their restoration 
to complete health may be slow. The following case is interesting as show- 
ing a favorable result, from opening the chest with a bistoury in an infant, 
that seemed almost moribund at the time of the operation, and whose 
death had been predicted by experienced physicians. The records are con- 
densed from my notes. 

" December 8th, 1873. Mary B., aged 5 months, nursing, inmate of 
New York Infant Asylum, has had a cough for three weeks, but it has 
been more frequent and severe during the last three or four days than pre- 
viously. Is pallid and weakly-looking. Dec 12th. Pulse, 120 per min- 
ute ; temperature, lOOf ° ; has flat percussion-sound over the entire left 
side of the chest, and a pleuritic, clicking sound is observed in the left 
scapular region ; respiration slightly abdominal, and accompanied by an 
expiratory moan ; respiratory murmur on left side distant, and broncho- 
vesicular or bronchial ; no appreciable bulging of intercostal spaces on this 
side ; circumference of left side of chest from half to three-fourths of an 
inch greater than that of the opposite side ; he is gradually losing strength ; 
and his features are pallid, and of a flabby appearance, notwithstanding 
the constant use of stimulants and tonics. Dec. loth. Pulse, 144; tem- 
perature, 100°. Dec. 22d. Pulse, 168; temperature, 991°. Dec. 26th. 
Pulse, 1G0; temperature, 101^°. Dec. 29th. Pulse, 144; temperature, 
991°. Jan. 8th, 1874. Pulse, 156; respiration, 60; temperature, 101°." 

On this day (January 8th) the presence of pus in the pleural cavity 
having been ascertained by the hypodermic syringe, an incision was made 
through the walls of the chest with a narrow bistoury, about one and a 
half inches below the angle of the scapula. Thin pus, tinged with blood, 
perhaps two ounces, escaped, and some air entered the chest during the 
operation. The opening remained fistulous, discharging pus, which was 
often unhealthy-looking and offensive, with intermissions of a day or two, 
till about the middle of June, when the flow ceased, and she has since re- 
mained well. 

I prefer, however, in general, the use of the aspirator for the removal 
of pus in the empyema of children. The removal of all the pus, which 
can be aspirated at a single sitting through an aspirator point of medium 
size, will ordinarily, I think, be sufficient to insure a favorable result, as in 
one of the cases detailed above ; for, though there is some pus remaining, 
it will be absorbed, provided that the quantity is not too large. Washing 
out the pleural cavity with tepid water, to which a little carbolic acid is 
added, no doubt expedites recovery. It is especially useful when the pus 
is fetid, as in the case last related. If the child do not progressively im- 
prove, or if the physical signs indicate a refilling of the cavity with pus, 
I would then establish a fistulous opening. Thus, in the case of a child 
aged about three years, who was brought to my clinique at Bellevue in 
the spring of 1875, Dr. Ackerman and myself removed about eighteen 



TREATMENT. 571 

ounces of pus by aspiration. There was great relief, but a few weeks sub- 
sequently it was brought back with symptoms and physical signs almost as 
grave as at first, when the Doctor judiciously established a fistulous open- 
ing, after which the case progressed favorably. 

Nervous Cough. 

A nervous cough sometimes occurs in children, especially between the 
ages of two or three and ten years. It may result from disease of the 
brain, from the second as well as first dentition, from some irritant in the 
intestines, as worms, and also from spinal irritation. Occasionally there 
appears to be no local cause, but a state of anremia, or a highly developed 
nervous temperament, to which it seems proper to ascribe the cough. 
Occurring under these last circumstances it corresponds with, and is some- 
times accompanied by, functional disturbance in the action of the heart, 
as palpitation. 

A nervous cough is short, painless, and without expectoration. It 
usually attracts little attention at first, but from its long duration the 
friends finally become anxious lest it betoken some serious disease. At 
times it may nearly subside if the patient lead a quiet life and the general 
health improve, and there are periods of recrudescence if the opposite 
conditions obtain. It may have a spasmodic character, especially in 
times of mental excitement, but in a less degree than the cough of per- 
tussis. If not properly treated, it usually continues several weeks or 
months, disappearing as the general health and the tone of the nervous 
system improve. It is not in itself a serious disease, nor does it lead to 
any ailment or produce any injury of the respiratory organs, but it is an 
unpleasant malady, and is liable to be mistaken for incipient tuberculosis 
if it occur in one decidedly cachectic, and belonging to a family predis- 
posed to phthisis. 

Treatment — If there is a local cause of the cough, measures calcu- 
lated to remove this, or at least to palliate its effects, are obviously re- 
quired. Especially should constipation, or any abnormality in the diges- 
tive function be corrected. But in many cases there is no apparent local 
ailment which produces the cough by its irritative effect, and the remedial 
measures must then be twofold, namely, measures designed to improve the 
general state, and secondly, measures designed to relieve the cough. Such 
measures are also required in most cases in which there is a local cause, 
provided that the cough do not cease when treatment calculated to remove 
this cause has been employed. 

For constitutional treatment no remedy is so useful in ordinary cases as 
iron. The following example shows the benefit which may result from the 
use of this agent, since in this case it effected a cure without the aid of 
other measures. B , aged 11 years, pallid and of spare habit, but ac- 



572 NERVOUS COUGH. 

five, and with good appetite, had been treated for this malady by different 
physicians but without improvement. His mother had died of tubercu- 
losis, and some at least of the physicians believed that he was in the 
commencement of the same disease. Finally he was placed under the 
care of the late Dr. Cammann, who, detecting the nature of the malady, 
wrote the following prescription : — 

R. Ferri. subsulphat., 5^s ; 
Acid, nitric, f5ss ; 
Aq. destillat., §ss. Misce. 
Dose, three drops four times daily in sweetened water. 

The cough disappeared in a surprisingly short time. If the appetite is 
poor the vegetable tonics are required in combination with iron. 

If the cough is frequent and troublesome, medicines which exert a 
direct controlling effect upon it are required in addition to the medicines 
and measures employed to improve the general state. For this purpose 
no remedy is so useful as the bromides, employed alone or in combination 
with belladonna. If there is no decided anaemia, and no local cause of the 
cough, the bromides and belladonna usually effect a cure without the em- 
ployment of constitutional measures, or if the case seem to require iron it 
may be given in the interval. The following is the prescription for a child 
of three years : — 

R. Tinct. belladonnas, gtt. xxxij ; 
Potas. bromid., 
Ammon. bromid., aa gj ; 
Syr. simplic, §ij. Misce. 
Dose, one teaspoonful twice daily. 

In 1871 I was asked to prescribe for a German boy, aged 8 J years, who 
had a cough of this kind of two months' duration, which latterly had been 
frequent and annoying. Within a week he was entirely relieved without 
other remedy, by the employment of tincture of belladonna, drops v, and 
bromide of ammonium, gr. v, twice daily. Outdoor exercise, or country 
residence and other regimenal measures which improve the general health 
are useful in ordinary cases. 



SECTION III. 
DISEASES OF THE DIGESTIVE APPARATUS. 



CHAPTER I. 

SIMPLE STOMATITIS, ULCEROUS STOMATITIS, FOLLICULAR STOMATITIS. 

Diseases of the digestive system are very frequent in infancy and 
childhood. They are for the most part readily recognized, and are more 
easily and quickly controlled by therapeutic agents, if rightly applied, 
than are the diseases of any other system. If misunderstood and im- 
properly treated, they may, even when mild and very manageable in their 
commencement, become chronic and obstinate, or even fatal, or they may 
lead to other and more dangerous diseases. It is necessary, then, that the 
physician should understand thoroughly the pathology as well as therapeu- 
tics of the digestive system, that he may make timely and correct use of 
the required remedies. 

The diseases of the buccal cavity in early life are for the most part 
inflammatory. The mildest is that known as 

Simple or Catarrhal Stomatitis. 

This form of catarrh occurs usually before the completion of first denti- 
tion, and it is most frequent under the age of one year. Giving rise in 
itself to no severe symptoms, and often being connected with other grave 
and dangerous maladies, it is, doubtless, in many cases overlooked. It is 
sometimes confined to a portion of the buccal surface, or is more intense 
in one part than in another. In other cases the catarrh is uniform, or 
nearly so, affecting the entire cavity of the mouth. 

Causes The common cause of simple stomatitis in infants is the same 

as that of most cases of gastro-intestinal inflammation at that age. This 
is the use of indigestible and therefore irritating food, uncleanliness, per- 
sonal and domiciliary; in fine, all those agencies which impair the general 
health, and enfeeble the digestive organs. Therefore, stomatitis, like en- 
tero-colitis, is more common in the city than in the country, and among 
the city poor than those in the better walks of life. Infants deprived of 
the mother's milk and given a diet which, with all care of preparation, is 



574 SIMPLE OR CATARRHAL STOMATITIS. 

a poor substitute for the natural aliment, are very liable to this disease. 
Beaumont ascertained from his. experiments on St. Martin that irritative 
changes produced in the stomach by indigestible substances were soon fol- 
lowed by similar changes in the buccal mucous membrane. Since in young 
infants any kind of artificial food is less digestible than the breast-milk, 
it is evident why those who are prematurely weaned or are carelessly fed 
are so liable to stomatitis. This inflammation is also sometimes due to 
irritating substances taken in the mouth, as drinks habitually too hot or 
too cold. Stomatitis is also present in measles and scarlet fever. It then 
corresponds with the cutaneous eruption, and disappears when that sub- 
sides. 

Another cause is dentition. The gum over the advancing tooth first 
becomes inflamed, and, other causes perhaps conspiring, the inflammation 
extends over more or less of the buccal surface. When due to dentition 
the stomatitis is more apt to be partial than when it arises from a consti- 
tutional cause. Mercury, in whatever form introduced into the system, 
excreted from the salivary glands, and flowing over the buccal surface, is 
an occasional though nowadays rare cause. 

Symptoms — Appearances Stomatitis, like other mucous inflamma- 
tions, is characterized by increased redness and more or less thickening ot 
the inflamed buccal membrane, by rapid proliferation and exfoliation of 
epithelial cells, and by an increased functional activity of the muciparous 
follicles. The heat of the mouth is sometimes augmented in an apprecia- 
ble degree. The gums in severe cases are swollen and spongy, and bleed 
easily if rubbed or pressed. The tongue is usually covered with a light 
fur, and the salivary secretion is augmented to such an extent sometimes 
as to dribble from the corners of the mouth. Often there is little suffering, 
but in other instances the patients are fretful, experience pain from the 
contact of solid food, and, if nursing, may even wean themselves from 
dread of pressure of the nipple. 

Simple stomatitis is not difficult of detection, provided attention is 
directed to the mouth. Inspection informs us of its presence and extent. 
A favorable termination may be confidently predicted, unless there is a 
state of marked cachexia, or a grave coexisting disease. If circumstances 
are unfavorable, simple stomatitis may terminate in a more severe form, 
as the ulcerous or diphtheritic. 

Treatment The physician should endeavor to ascertain the cause, 

and, if possible, should remove it by appropriate medicinal or hygienic 
measures. Sometimes no special treatment is required, as in measles or 
scarlet fever. When the primary affection terminates, the stomatitis dis- 
appears of itself. If dentition is the cause, and there is much fever and 
fretfulness, it has been the common practice to scarify the gums, but this 
operation is in my opinion seldom advisable. A few doses of the bro- 
mide of potassium relieves the fretfulness, and mucilaginous and mild 



ULCEROUS STOMATITIS. DID 

astringent lotions suffice for the catarrh. Borax is a good local remedy 
used either with honey or with glycerine and water ; one part of borax to 
three of honey, or a drachm of borax to an ounce of glycerine and water. 
A weak solution of alum is also a useful topical remedy. With either of 
these remedies in a favorable condition of system, and without any serious 
coexisting disease, the stomatitis is relieved. 



Ulcerous Stomatitis. 

In ulcerous stomatitis, the anatomical characters are those of severe 
simple stomatitis, with the additional element which gives it the name by 
which it is designated. 

The inflammation usually begins upon the gums and extends along the 
buccal surface. Wherever it commences, there soon appear little white 
points in the mucous membrane, producing slight prominence of it. These 
points, which are inflammatory exudations, mainly fibrinous, gradually 
enlarge. Some unite and give rise to large irregular ulcerations ; others 
remain isolated, producing ulcers which are smaller and of more regular 
shape. There is, indeed, no uniformity as regards the size and form of 
the ulcers. In the folds of the buccal membrane they are apt to be elon- 
gated, while^ inside the lips, or where the surface is smooth, the circular or 
oval form predominates. It is a noteworthy fact that the exudation pene- 
trates the mucous membrane as in the usual form of diphtheritic inflam- 
mation, so that the ulcer which results causes destruction of the mucous 
layer, and cure is effected by cicatrization. 

Ulcerous stomatitis is usually confined to that part of the buccal surface 
which covers the gums, or is in their immediate vicinity, but in some 
instances it affects nearly every part of the cavity of the mouth. 

If the disease is severe, there is considerable swelling around the ulcers, 
but the swollen part is soft and cushiony, and not very tender on pressure. 
The soft and yielding nature of the swelling serves as a means of diagnosis 
between this disease and the premonitory stage of gangrene, since in the 
latter affection the swollen part is more indurated. 

If the disease grows worse, more ulcers appear, and those already pre- 
sent grow deeper and wider, and their edges more vascular. 

If, on the other hand, there is improvement, the swelling subsides, the 
ulcers become more clean, their bases approach the level of the mucous 
membrane and present a granulating appearance. Finally the mucous 
layer is reproduced. A considerable time after the ulcers are healed, 
the new membrane which occupies their site has a redder hue than the 
adjacent surface. 

Causes — Ulcerous, like simple, stomatitis is most frequent in the 
families of the poor. Personal uncleanliness, poor food, a residence in 
apartments dirty, humid, or in other respects insalubrious, favor its de- 



576 FOLLICULAR STOMATITIS. 

velopment. In fine, a cachectic condition, however produced, is a com- 
mon predisposing cause. It frequently occurs when the system is reduced 
or enfeebled by acute diseases, as after the essential fevers and thoracic 
and intestinal inflammations. In protracted entero- colitis of infants, it is 
sometimes severe and obstinate, and a case in which this complication 
arises usually ends unfavorably. The abuse of mercury is an occasional 
cause of this form of stomatitis, as well as of simple catarrh. Jaccoud 
states that Bergeron established the fact that ulcerous stomatitis is propa- 
gated among soldiers by contagion, and he adds "it is very probable that 
it is the same in infants." 

Symptoms — The symptoms in ulcerous stomatitis are more severe than 
in the simple form. There is more pain, more salivation, and more fret- 
fulness. The ulcerated surface is sometimes very tender, so that there is 
but little sleep. Drinks, unless bland and lukewarm, are painful, and, if 
the ulcers are on the lips or the front of the mouth, the infant nurses less 
eagerly than usual, and even with reluctance, sometimes weaning itself. 
Occasionally the submaxillary glands are tumefied, hard, and tender. 
The breath has an offensive odor. In mild cases in which the stomatitis 
is of limited extent, this odor may scarcely be noticed, but in severe cases 
it is almost like that exhaled from putrid substances. The febrile move- 
ment is usually slight. 

Prognosis. — A favorable prognosis may be given unless the patient is 
in a decidedly cachectic condition, or there is a serious coexisting disease, 
under which circumstances the case may be protracted. If death occur, it 
is due to the cachexia, or to some pathological state quite distinct from the 
stomatitis, most frequently entero-colitis. Ulcerous stomatitis, when the. 
ulcers are small and the inflammation of limited extent, is of course more 
easily cured than when it is extensive and the ulcers are large. 

This disease is very liable to return, unless the general health is good. 

Treatment The physician should endeavor to ascertain the cause of 

the stomatitis, and so far as possible should remove the patient from its 
influence. It is often necessary, in order to insure a speedy recovery, to 
recommend a change in regimen, especially as regards diet and cleanliness. 
If the patient live in damp, dark, and dirty apartments, the family should 
seek a better residence, and he should be taken daily in the open air. 

Tonic remedies are generally required. The ferruginous preparations 
may be advantageously given, or the vegetable tonics, or the two in com- 
bination. In selecting the internal remedies we must regard the antece- 
dent disease, if there be any, which the buccal inflammation complicates, 
and on which it depends. For that large proportion of cases in which 
there is chronic intestinal inflammation, the liquor ferri nitratis with tinc- 
ture of Colombo administered in simple syrup will be found useful. For 
local treatment Trousseau recommends occasional applications of nitrate 



APHTHOUS STOMATITIS, 577 

of silver or muriatic acid as a caustic, and in the intervals a wash of equal 
parts of borax and honey. 

The chloride of lime is also considerably used in Paris. It is recom- 
mended by Rilliet and Barthez. It is applied dry to the ulcerated surface 
twice daily, and in the interval the mouth is washed with simple water. 
This treatment is continued till the ulcers present a healthy appearance 
and begin to cicatrize. Then a weak solution of chloride of lime is em- 
ployed, one grain to forty-five of the vehicle. By this treatment a cure is 
usually effected. Bouchut prefers using chloride of lime with honey, one 
drachm to the ounce. 

But painful applications are not required. The remedy which is most 
employed in this country and in Great Britain is chlorate of potassium. It 
often acts like a specific for this as well as other forms of stomatitis. It 
may be given dissolved in water with sugar, or with one of the syrups, to 
render it more palatable. The dose is from two to five grains every two 
hours. It should be allowed to run over the affected part, as it is believed 
to have a local action. 

R. Potass, chlorat., 5j ; 
Mellis, §ss ; 
Aquse, §ij. 
One teaspoonful every two hours. 

Of all topical remedies in common use, chlorate of potassium is probably 
the most efficacious. Some physicians prefer the chlorate of sodium, on 
account of its greater solubility. If this wash is too painful on account of 
the irritable state of the ulcers, it may be used less frequently, and borax 
applied in the interval. 

Aphthous Stomatitis, 

Aphthous stomatitis may occur at any age, but it is most frequent in 
childhood. It is sometimes designated follicular stomatitis, but the disease 
affects other parts of the mucous surface, as well as the seat of the follicles. 
At first a vascular injection is observed, and within a few hours a whitish 
exudation occurs immediately under the intact epithelium, and upon the 
corium, in small round or oval isolated spots. The smallest of these 
patches are not larger than a pin's head, but most of them have a diameter 
of one to two lines, and they cause slight prominence of the surface. In 
two or three days the exudation softens ; and the epithelium, which covers 
it, is thrown off, producing an ulcer, superficial, without induration of its 
edges, but sensitive to the touch. It heals in one to two weeks, leaving 
only a reddish spot or stain, which soon fades. Sometimes two or more 
aphthae unite, forming a patch, and an ulcer of correspondingly large size. 
The seat of aphthous stomatitis is usually the internal surface of the lips 
and cheeks, the gums, tongue, and occasionally the roof of the mouth. 
37 



578 FOLLICULAR STOMATITIS. 

Causes — Probably in most instances the exciting cause is some de- 
rangement of the digestive organs, which may not be appreciable. We 
sometimes observe it in cases of diarrhoea. Occasionally, especially in 
spring and autumn, two children in a family are affected, at the same time, 
or two or more in a school, so that it presents an epidemic character. 
Children surrounded by bad hygienic conditions, as in the tenement houses 
of the cities, are more liable to this as well as other forms of stomatitis, 
than are children who live in clean and airy localities, and have nutritious 
and wholesome diet. 

Symptoms The constitutional symptoms in a large proportion of cases 

of aphthae are slight. In twelve children affected with this disease Billard 
found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the child when 
they are pressed, and its fretfulness. Solid food and even drinks, unless 
bland and unirritating, are badly tolerated. The salivary secretion is 
also augmented. 

In those rare cases in which the ulcer becomes confluent or gangrenous, 
the state of the patient is really serious. There is then often gastro- 
intestinal disease. The symptoms indicate prostration. The pulse is 
feeble, the countenance pallid, and the body and limbs become wasted. 

Diagnosis This is easy. The only disease with which it is liable to 

be confounded is ulcerous stomatitis. In the ulcerous form there is ante- 
cedent and accompanying stomatitis affecting a considerable part, if not 
the entire buccal cavity, while in the follicular form the inflammation is 
ordinarily confined to the immediate vicinity of the ulcers. The char- 
acter of the ulcers serves also as a means of distinction. In ulcerous 
stomatitis there is great variety as to size and form, while in aphthous 
stomatitis there is great uniformity in both these respects. The small, 
circular ulcers are characteristic of the follicular inflammation. Before 
the ulcerative stage the circumscribed character of the eruption serves to 
distinguish this form of stomatitis from other local diseases affecting the 
cavity of the mouth. 

Prognosis. — Aphthous stomatitis usually ends favorably ; but, if the 
ulcers become concrete or gangrenous, the health is seriously affected, and 
a more cautious prognosis should be expressed. The unhealthy appearance 
of the mouth and the real danger are often more due to the depressing 
effect of some concomitant disease than to the stomatitis. 

Treatment In ordinary aphthous stomatitis, which is discrete and 

attended by little or no constitutional disturbance, local remedies suffice to 
cure the disease. Demulcent drinks or applications to the mouth should be 
used, as the mucilage from gum acacia, marsh-mallow, or flaxseed. Mild 
astringent lotions with the demulcent are also beneficial. The mel boracis 
is one of the best and most agreeable applications. It may be placed in 
the mouth with a spoon, or applied with a camel-hair pencil. If there is 



THRUSH — ANATOMICAL CHARACTERS. 579 

much tenderness of the ulcers, with restlessness, a small quantity of some 
opiate should be added to the lotion, or it may be administered separately. 

With this simple treatment the ulcers generally soon heal, and the 
health of the patient is restored. If, however, the ulcers are quite pain- 
ful, and not disposed to heal, or are healing tardily, they may be touched 
lightly with a pencil of nitrate of silver, or, as Barrier recommends, 
hydrochloric acid in honey of roses. This diminishes the tenderness and 
expedites the healing process. 

If, as may in rare cases occur, the ulcerations are numerous, and are 
accompanied by considerable fever, there may be symptoms indicative of 
cerebral congestion, or even premonitory of convulsions. In such cases 
laxatives and the soothing effect of one of the bromides and sometimes of 
the warm foot-bath are required. 

If there is an unhealthy appearance of the ulcers, if they gradually 
enlarge or become concrete, or gangrenous, indicating a cachectic state, 
tonics should be employed with nutritious and easily digested diet, and 
anti-hygienic influences should so far as possible be removed. 



CHAPTER II. 

THRUSH 

The terms thrush, sprue, and muguet, the last from the French, are 
synonymous. They are used to designate a particular form of inflamma- 
tion of mucous surfaces, the peculiar feature of which is the presence of 
points or patches of a curdlike appearance on the inflamed surface. 

The usual seat of thrush is the buccal membrane, but occasionally it 
affects the faucial, pharyngeal, or oesophageal. It is very rare in the sub- 
diaphragmatic portion of the digestive tube, but a few such cases have 
been reported by Billard and others. It never affects the membrane of 
the nostrils, larynx, or bronchial tubes, and it very seldom occurs in any 
other part of the alimentary canal without also being present in the 
mouth. Thrush, then, is a stomatitis, pharyngitis, or oesophagitis, or a 
gastro-enteritis, with the additional element which I have described. 

Anatomical Characters — The first stage of thrush is that of simple 
inflammation of the mucous surface. There next appear minute semi- 
transparent points or granules, which, increasing, soon become white and 
opaque. Some of them remain as points, while others, extending, and 
perhaps coalescing with those adjoining, form patches of greater or less 
extent. The white points or patches are unequally elevated. Their 
central part, which was first formed, is most raised, while their circum- 



580 THRUSH. 

ference projects but little above the epithelium. Their highest elevation 
is not ordinarily more than a line above the surface. They are smaller 
in the pharynx and oesophagus than when occurring upon the buccal sur- 
face. They resemble closely, in color and consistence, portions of curdled 
milk, and the nurse often mistakes them for such, and neglects to call 
attention to the state of the mouth. They are readily detached by a little 
force, but are speedily reproduced. Their color in the first days of the 
sprue is white, and sometimes this color continues. In other cases they 
assume, if the disease is protracted, a yellow hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells, and in part of a vegetable growth. 
This parasitic plant is in most cases the oidium albicans. Like other con- 
fervas, it consists of roots, branches, and sporules. The roots are trans- 
parent, and they penetrate the epithelial layer, sometimes even to the 
basement membrane. The branches divide and subdivide at an acute 
angle, and under the microscope they are seen to consist of elongated 
cells, with one or two nuclei. Around these branches are numerous 
sporules. In two or three instances I have examined the product of 
thrush removed from the oesophagus, and in both the parasitic plant was 
the penicillium glaucum, or a conferva closely resembling it. 

In the mildest form of thrush, this morbid product is in points or small 
patches. If the patches are of large extent, especially if, as rarely hap- 
pens, a considerable part of the buccal surface is covered by them, there 
is generally a state of great prostration and danger, from some antecedent 
or concomitant disease. Thrush is, indeed, often the sequel of some grave 
affection, as pneumonitis or gastro-intestinal inflammation. Its complica- 
tion with the last-named disease is common in young, ill-fed infants, 
especially those deprived of the breast-milk, and such cases are very apt 
to be fatal. 

Hence, some writers, who have observed infantile diseases in foundling 
hospitals, regard thrush as one of the most serious maladies of early life. 
Valleix, in a book of seven hundred pages relating to diseases of children, 
devotes more than one-third to the consideration of muguet. Of twenty- 
four cases, the records of which he publishes, twenty-two died, but their 
death was due to gastro-intestinal inflammation, which the author con- 
sidered a part of the more general disease, muguet. Doubtless the same 
cause which produced the stomatitis, with the confervoid growth, in these 
infants, also produced the fatal gastritis or gastro-enteritis, occurring with- 
out this growth. Nevertheless it seems better to restrict the term sprue, 
thrush, or muguet to those inflammations of mucous surfaces which are 
accompanied by the parasitic growth. I reject, then, from my descrip- 
tion of the anatomical characters of thrush, those subdiaphragmatic 
phlegmasias which some writers consider an important part of severe 
muguet, and regarded them as complications, unless indeed the case is one 



SYMPTOMS — CAUSES. 581 

of those exceptional ones in which the parasite has lodged and grown 
upon the gastric or intestinal surface. This explanation seems necessary 
in order to understand the different statements of writers in relation, not 
only to the anatomical characters of thrush, but also in reference to its 
mortality. 

The frequent coexistence of thrush with gastro-intestinal inflammation, 
has been remarked in the hospitals of Europe, and in the Infant Asylum 
and the Child's Hospital, in this city. In the post-mortem examinations 
of those who have died in these last institutions, having thrush at the time 
of death or immediately prior to it, and who for the most part have been 
infants under the age of three months, I have frequently found evidences 
of inflammation in every division of the alimentary canal. The confer- 
void growth was, however, seldom found below the fauces, and never below 
the oesophagus. 

Symptoms The symptoms in thrush are not different in most cases 

from those of simple inflammation. In the mildest cases they are chiefly 
of a local nature, such as have already been described in our remarks on 
simple stomatitis. If the inflammation is more extensive, especially if it 
affect the fauces and oesophagus, the infant becomes feverish and fretful, 
and the inflamed surface is hot, reel, and tender. In the worst forms of 
thrush this surface not only presents the ordinary features of severe inflam- 
mation, namely heat, redness, and tenderness, but it is sometimes deficient 
in the natural secretion, so as to present a dry or parched appearance. It 
is in these cases that there is often a more extensive inflammation than 
that of the buccal or oesophageal membrane. The sub-diaphragmatic por- 
tion of the digestive tube is inflamed. In these severe cases thirst, loss of 
appetite, restlessness, vomiting, and frequently diarrhoea occur. The coun- 
tenance is anxious and pale ; there is rapid emaciation, and, if the disease 
is not arrested, a state of extreme prostration soon arrives. The twenty- 
four severe cases related by Yalleix, already alluded to, twenty-two of 
which were fatal, were examples of this severe form. 

Causes. — Thrush is most apt to occur in those who are constitutionally 
feeble, or who are enfeebled by disease, or by unfavorable hygienic con- 
ditions. Cachexia is a cause common to thrush and most other subacute 
inflammations of the alimentary canal. The most obvious and common 
of the unfavorable hygienic conditions alluded to is the continued use of 
indigestible and improper food. It is, therefore, a common disease among 
foundlings, in institutions where these unfortunates are received, since they 
not only breathe an atmosphere which is often impure, but are deprived of 
the mother's milk, and are so frequently given a diet which is a poor sub- 
stitute for it. Among the poor of the cities thrush is common, since with 
them, from necessity or choice, there is the greatest neglect of sanitary 
requirements. Exposure to humidity, to variations in temperature, in- 
creases the liability to the disease, though in less degree than defective 



582 THRUSH. 

alimentation. Billard and Valleix agree that thrush is more frequent in 
the warm months than in the cold, that its maximum frequency is in the 
months of July, August, and September. Cases in the Infant Asylum 
and Child's Hospital, of this city, have appeared to me to correspond in 
this respect with those related by Billard and Valleix. Various writers 
have mentioned the age at which thrush is most apt to occur, as one of the 
predisposing cases. Uncomplicated thrush is not common above the age 
of six months. Most cases occur under the age of three months. Infants 
of the age of one or two weeks, if in addition to lactation they are spoon- 
fed by nurses over-anxious that they should thrive, are apt to take the dis- 
ease. Thrush is not uncommon in children under the age of eighteen 
months who are suffering from exhausting diseases. It is then an unfavor- 
able prognostic sign. 

Diagnosis. — This is easy so far as thrush in the mouth is concerned, 
for simple inspection by one familiar with the disease is all that is required 
in order to discover it. The presence of thrush in portions of the alimen- 
tary canal hidden from view cannot be positively ascertained. 

The vomiting, diarrhoea, pain or fretfulness, emaciation, and rapid sink- 
ing, which sometimes accompany severe forms of thrush, indicate gastro- 
intestinal inflammation, to which the attention of the practitioner should 
be chiefly directed. 

Prognosis. — The duration of thrush varies according to its intensity, 
and the favorable or unfavorable condition of the child. If it is slight 
and the health of the infant otherwise good, it may often be cured in two 
or three days. Under other circumstances it may continue as many weeks 
or even longer, before it is entirely removed. 

When thrush occurs in connection with gastro-enteritis, the mortality is 
very great. It has been already stated that in Valleix's twenty -four cases 
twenty-two were fatal. M. Auvity estimates the mortality of such cases 
at nine in ten, and M. Godinat at two in three. 

Treatment As one of the most common causes of thrush is the use 

of indigestible or improper food, the physician should ascertain the nature 
of the infant's diet, and if it is faulty should direct a better. In many 
cases the infant is bottle-fed. It should be given only the mother's milk 
if practicable, or that of a healthy wet-nurse. This change of alimenta- 
tion often removes the sole cause of thrush in the young infant, so that it 
rapidly recovers. 

If artificial feeding is necessary, such diet should be advised as is directed 
in our remarks on the treatment of the diarrhoeal maladies. There is often 
in thrush an excess of acidity in the digestive tube, and an alkali is re- 
quired. Trousseau recommends the addition of saccharate of lime to the 
milk. Children with this disease should also be taken from filthy and 
damp apartments, to those in which the air is pure and dry, and their 
mouths and persons should be kept clean. 



TREATMENT. 583 

The remedy in common use in the treatment of thrush, and which is 
usually effectual, is borax. This, if applied sufficiently often to the affected 
membrane, not only destroys the parasitic growth, but prevents its repro- 
duction. It is commonly employed with honey, or in a powder with sugar 
or dissolved in water. The official mel boracis, consisting of one part of 
borax to eight of honey, is so much used in families that it may be con- 
sidered almost a domestic remedy. There is, however, an objection to 
using any application for the removal of thrush which contains either sugar 
or honey, since either substance remaining in the mouth would rather pro- 
mote the growth of the parasite. Still, it is desirable to employ a wash 
of such consistence that it will remain a longer time in contact with the 
buccal surface than will a simple solution in water. I know no better 
vehicle for the borax than glycerin, which has the advantage of consis- 
tence, does not undergo any chemical change, and has no unpleasant flavor. 
The borax may be used dissolved in glycerin, with or without some flavor- 
ing ingredient : — 

R. Sodse borat., 5j ; 

Glycerinse, 3ij ; 

Aquae 3yj. Misce. 

Borax should be used four or five times daily, and continued for a time 
after the disease has disappeared from sight, since the roots of the plant 
must be destroyed or the branches are rapidly reproduced. It should be 
applied by a camel-hair pencil, or with a soft cloth upon the finger or a 
stick. It should be so freely used, in extensive and severe forms of the 
disease, that the infant will swallow some, as the entire oesophagus is apt 
to be affected in such cases. In the intervals between the applications of 
borax, if the buccal surface is hot, dry, and tender, so as to increase the 
fretfulness of the infant, it is well to use mucilaginous washes, as the 
mucilage of acacia or mallows. If the disease continue notwithstanding 
the use of these measures, the mouth should be occasionally washed with 
a weak solution of nitrate of silver or sulphate of zinc : — 

R. Zinci sulph., gr. ii-iv ; 
Aq. rosae, §ij. Misce. 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which the thrush complicates. The remedial 
measures which I have mentioned then become subordinate to those em- 
ployed for the graver disease. When this disease is relieved and the gen- 
eral health improves, thrush is more easily and permanently cured than 
during the state of feebleness and ill-health. 



584 GANGRENE OF THE MOUTH 



CHAPTER III. 

GANGRENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are attended 
by little danger, but the one which we are next to consider, is among the 
most fatal of early life. It is gangrene of a portion of the cheek or gums, 
or of both. It is described by writers under various names, as cancrum 
oris, noma, necrosis infantilis, aqueous cancer of infants. 

Anatomical Characters Gangrene of the mouth is sometimes 

preceded by ulceration of the mucous membrane, at the point where it is 
about to commence, but in other cases this membrane is entire. The 
tissues at the point of attack, which is most frequently the inside of the 
cheek, become inflamed, thickened, and indurated. The induration ex- 
tends, and soon the purple hue of gangrene appears and increases. The 
next stage in the progress of gangrene is sloughing of the portion the 
vitality of which is lost. 

The slough does not present the appearance of uniform decay. While 
the color is generally dark, there are in the mass fibres of connective tissue 
or even bloodvessels, which remain unchanged or are but partially decom- 
posed. After separation or sloughing of the part where the vitality is first 
lost, the surface of the excavation, if the disease is not checked, has a 
dark, jagged, and unhealthy appearance. Commencing with the mucous 
membrane and the tissue immediately underlying it, the disease extends 
on the one side towards the skin, and on the other towards the deeper- 
seated structures of the jaw. According to Billard, the swelling which 
precedes and surrounds the gangrene is in great part (edematous. 

This disease is occasionally primary, but in a large proportion of cases 
it is secondary. Occurring secondarily, its symptoms are often masked by 
those of the antecedent and coexisting affection. Under such circum- 
stances attention is sometimes first directed to the mouth, by the loosening 
of one or more of the teeth, or the appearance on the skin of a livid cir- 
cular spot, which indicates the approach of the disease to the cutaneous 
surface. The mucous membrane presents a dark-red appearance to the 
distance of a few lines beyond the point of gangrene. It covers tissues 
which are inflamed and indurated and about to become gangrenous. 

The tongue is usually more or less swollen, unless the disease is mild ; 
an offensive odor arises from the gangrene, due to the evolution of sul- 
phuretted hydrogen and other gases. There is great difference in the 



AGE — CAUSES. 585 

extent of the destruction, and the gravity of the disease, in different cases. 
It may sometimes be arrested by proper applications and a favorable 
change in the general health of the child at an early period, when there is 
little loss of substance. In other cases it extends till it perforates the 
cheek, or even destroys a considerable part of the side of the face, and, 
extending inwards, attacks the periosteum of the maxillary bone, destroy- 
ing the gum and teeth, and denuding the alveoli. Recovery, if it take 
place at all under such circumstances, is with the loss of a portion of the 
bone, and with deformity. 

The duct of Steno is sometimes included in the gangrenous portion, but 
it commonly resists the destructive process, and remains pervious. 

Age The age at which gangrene of the mouth occurs is usually be- 
tween two and six years. In twenty-nine cases collated by Rilliet and 
Barthez, twenty-one were between the ages of two and six years, and the 
remaining eight were from six to twelve years old. Of the cases which 
have fallen under my observation, all were between the ages of two and 
six years. It is seen that the period of greatest frequency of gangrene of 
the mouth is different from that at which the ordinary forms of stomatitis 
occur. 

Gangrene of the mouth may, however, occur under the age of one year. 
Billard reported three cases under the age of one month, but in two of 
these the disease does not appear to have been sufficiently marked to ren- 
der it certain that they were genuine cases. 

Causes — Gangrene of the mouth usually occurs in those whose systems 
are reduced or cachectic. It is, therefore, more frequent among the poor 
than those in comfortable circumstances ; in the city than in the country. 
It is more frequently observed in asylums for children than in private 
practice. Half the cases which I have seen have been in these institu- 
tions. If the constitution is naturally good, it can only occur in those 
long deprived of pure air and wholesome nutriment, or those enfeebled by 
disease. 

Among the diseases which have been known to terminate in or be fol- 
lowed by gangrene of the mouth, are the pulmonary and intestinal inflam- 
mations, hooping-cough, and the fevers, both eruptive and the non-eruptive. 
Rilliet and Barthez have published a table of ninety-eight cases in which 
gangrene resulted from other diseases. In forty-one of these the antece- 
dent disease was measles, in five scarlet fever, six hooping-cough, nine 
intermittent fever, nine typhoid fever, seven mercurial salivation, and five 
enteritis. It is seen that the essential fevers were the most frequent cause 
of the gangrene. Of forty-six cases collected by MM. Bouley and Cail- 
lault, the antecedent disease was measles in all but five. In this city, also, 
a larger number occur from measles than from any other disease. 

One reason why so many cases of gangrene occur as a sequel of measles 



586 



GANGRENE OF THE MOUTH?* 



•- • 



is probably because this disease is accompanied by stomatitis. Simple or 
ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth chiefly in con- 
sequence of injudicious treatment, which has lowered the vitality of the 
system. Rilliet and Barthez mention the case of a child four years old, in 
whom gangrene commenced at the twenty-ninth day of primitive pneu- 
monia. This child had been reduced by the application of twelve leeches, 
three scarifications, a large blister, and by the use of absolute diet. 

The misuse of mercury was once a much more frequent cause of gan- 
grene than at present, at least in this country, since this agent was formerly 
much more employed than now. In fact most of the affections of infancy 
and childhood in which mercurials were formerly employed are now treated 
without it. 

Symptoms Gangrene of the mouth so often occurs in connection with 

other diseases, that its symptoms are in a large proportion of cases blended 
with those which arise from a distinct pathological state. 



Fig. 24. 




There is usually prostration more and more pronounced as the gangrene 
extends. The features are ordinarily pallid, but occasionally their normal 
color is preserved for a time ; the expression of the face is melancholy, 
but composed. Sometimes the child is fretful, if disturbed ; at other 
times it will quietly consent to an examination. The suffering is not 
proportionate to the gravity of the disease. There is less pain often than 
in some of the forms of stomatitis which are unattended with danger. 



\ • DIAGNOSIS. 587 

As the disease advances, the body and limbs gradually waste, the eyes 
are hollow, or, if the gangrene is near the orbit, the eyelids become 
oedematous, the lips are infiltrated, and both the lips and nostrils are 
often incrusted. If the cheek is perforated, alimentation is rendered 
more difficult, and the appearance of the child is melancholy in the 
extreme. 

The tongue is usually moist ; it is occasionally swollen. The saliva 
flows from the mouth, either pure or mixed with offensive sanguinolent 
matter. Unless the disease is slight, there is the peculiar gangrenous 
odor. The appetite is sometimes poor, at other times it is preserved 
through the whole sickness. There is no vomiting or looseness of the 
bowels, unless from a complication. The thirst is usually great, and the 
pulse is accelerated and feeble, except in mild cases. 

The skin in the commencement of gangrene is hot. When the vital 
force is much reduced, and especially as the disease approaches a fatal 
termination, the face and limbs become cool, and the surface generally 
presents a waxen or ashy appearance. There is no derangement of the 
respiratory system. Those cases which are attended by a cough or acceler- 
ated respiration are really cases of bronchitis or pneumonitis, coexisting 
with the gangrene. 

Diagnosis Gangrene of the mouth is easily diagnosticated. In those 

cases in which ulceration precedes the gangrene, it might be mistaken in 
its first stages for that form of ulcerous stomatitis in which the ulcers 
assume an unhealthy appearance. The following are the distinguishing 
features of the two affections : Around the ulcer where gangrene is about 
to commence the tissues are greatly thickened and indurated, or cedema- 
tous, while ulcerous stomatitis begins with a submucous deposit of fibrin, 
and is attended by little thickening of the surrounding parts, and little or 
no induration or oedema. In ulcerous stomatitis the skin over the seat of 
the disease presents its normal appearances, whereas in gangrene it presents 
a distended and shining appearance. The destructive process in ulcerous 
stomatitis is also more limited than in gangrene. Deep ulcerations do not 
occur, or are rare. Ulcerous stomatitis is more readily healed, and it 
leaves no eschar, contraction, or deformity. 

The differential diagnosis of gangrene of the mouth from those cases 
of follicular stomatitis in which the ulcers occupying the seat of the fol- 
licles assume a gangrenous appearance, must be made by a consideration 
of the same facts or particulars which serve to distinguish it from ulcerous 
stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles this dis- 
ease in some of its features. But the pustule always begins on the skin, 
while gangrene is. a disease of the mucous surface primarily. In gan- 
grene, therefore, the chief destruction is of the mucous membrane and of 



588 GANGEENE OF THE MOUTH. 

the submucous tissue, while in malignant pustule the chief destruction is 
of the skin and the subcutaneous tissue. 

Prognosis — This depends not only on the extent of the gangrene, 
but the nature of the disease, if there be one, which gave rise to it, and 
the degree of cachexia. If it occurs in connection with or as a sequel of 
one of the least debilitating diseases, and there is considerable vigor of 
system, it may often be arrested when it has destroyed only the mucous 
and subcutaneous tissues, so that no deformity results. The friends may 
congratulate themselves if the case terminate so favorably. In the graver 
cases, when the gangrene extends till it destroys the periosteum of the 
maxillary bone on the affected side, and perhaps perforates the cheek, if 
the child recovers it is with the permanent loss of teeth, tedious separation 
of the necrosed bone, and a cicatrix, which is apt to interfere with the 
free use of the jaw. Death is, however, the more common termination of 
severe cases. Occasionally the gangrene destroys the continuity of a 
bloodvessel, causing abundant hemorrhage, and accelerating the fatal 
result. In most cases, however, there is little or no hemorrhage, in con- 
sequence of coagulation in the vessels. 

Another serious complication occasionally arises, namely, gangrene of 
other parts, as of the external genital organs. The English editor of 
Bouchut's treatise on diseases of children, relates the following interesting 
case, from the Transactions of the Edin. Medico-Chir. Society : — 

An infant eight months old became affected with gangrene of the face, 
head, and hands. " The right ear and the entire hairy scalp were of an 
intensely black color, and on both cheeks patches existed about the size of 
a half-crown piece. The right thumb and the backs of both hands were 
similarly affected. The child was noted to have been restless and feverish 
on May 22d, and on the 23d a slightly darkened ring was found to have 
formed round the thumb, about the middle of the first phalanx ; in a few 
hours the whole thumb was gangrenous, and the dorsum of the hand became 
involved. On the ear the gangrene commenced with the appearance of a 
fleabite, and subsequently extended rapidly to the scalp, assuming a re- 
markable regular form, and giving to the child the appearance of wearing 
a black skullcap. The pulse was observed to be very feeble. . . . Death 
took place in twelve hours from the first appearance of gangrene on the 
thumb, the child being sensible and continuing to suck well, up to a few 
minutes before death." 

Rilliet and Barthez state that pneumonitis is apt to arise- in the course 
of gangrene of the mouth. Such a complication evidently diminishes 
materially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident, from the 
nature of the disease, that the duration is very different in different cases. 
The physician's attendance may be required for a week or two or for sev- 
eral weeks. 



TREATMENT. 589 

Treatment As gangrene of the mouth is eminently a disease of de- 
bility, all anti-hygienic influences should be removed, and the most nour- 
ishing diet, together with tonics, be recommended. The ferruginous 
preparations or the bitter vegetables are required. 

As soon as the physician is called, he should endeavor to arrest the 
gangrene, accelerate the detachment of the slough, and produce a healthy 
and granulating state of the surrounding tissues. This is best effected by 
applying a highly stimulating or even escharotic agent to the inflamed 
surface underneath and around the gangrene. For this purpose a great 
variety of substances have been used by different physicians, such as acetic, 
sulphuric, nitric, and hydrochloric acids, nitrate of silver, the acid nitrate 
of mercury, chloride of antimony, and even the actual cautery. 

M. Taupin recommends, after removing a considerable part of the gan- 
grenous substances with scissors or some instrument, the application of 
strong muriatic acid, and, when the slough is detached, of dry chloride of 
lime. 

Rilliet and Barthez advised the use twice daily of muriatic acid or the 
acid nitrate of mercury, applied by a brush upon and around the slough, 
followed immediately by the application of dry chloride of lime, when the 
mouth is to be thoroughly washed with water from a syringe. They di- 
rect in the interval frequent ablution with water. After the slough has 
separated, the escharotic is to be discontinued, and the chloride of lime 
used alone. If gangrene extend to the skin, a crucial incision is to be 
made and the escharotic applied, after which powdered cinchona is intro- 
duced and retained by a plaster. This treatment is to be continued till 
the gangrene is arrested and the decayed portion removed. Barrier, 
Talleix, and most French writers, recommend essentially the same treat- 
ment, namely, the application of undiluted escharotic agents. 

A safer, less painful, and, in my opinion, preferable treatment, is that 
employed by many British and American physicians, namely, the use of 
escharotic agents diluted, or, if applied in their full strength, such as are 
least active and penetrating. Some employ from the first topical treat- 
ment which is astringent and stimulating rather than escharotic, and they 
report satisfactory results. 

Dr. Gerhard believes ;; the best local applications are the nitrate of sil- 
ver, if the slough be small in extent ; if much larger, the best escharotic 
is the muriated tincture of iron, applied in the undiluted state. After the 
progress of the disease is arrested, the ulcer will improve rapidly under an 
astringent stimulant, such as the tincture of m'yrrh, or the aromatic wine 
of the French Pharmacopoeia." 

The local treatment recommended by Evanson and Maunsell I believe 
to be preferable to that advised by any of the writers from whom I have 
quoted. I have seen it so successful, that I should employ it in all ordi- 
nary cases from the first visit. A knowledge of this treatment will be best 



590 GANGRENE OF THE MOUTH. 

imparted by quoting from the authors (Diseases of Children, 2d Amer. 
edit., page 188) : " The lotion which we have found by far the most suc- 
cessful is a solution of sulphate of copper, as employed by Coates in the 
Children's Asylum. His formula is as follows : — 

"R. Cupri sulph., ^ij ; 

Pulv. cinchonse, §ss ; 
Aquae, ^iv. M. 

" This is to be applied twice a day very carefully to the full extent of 
the ulcerations and excoriations. The addition of the cinchona is only 
useful by retaining the sulphate of copper longer in contact with the 
edges of the gums. A solution of the sulphate of zinc, 5j to an ounce of 
water, by itself or combined with tincture of myrrh, Dr. Coates found to 
be also useful in some cases.' ' 

A moment's reflection will show us that the above treatment is far 
preferable, provided that it is equally effectual in arresting the gangrene, to 
the treatment by the strong escharotics which some of our best prac- 
titioners employ. 

' Take, for example, the use of pure nitric or muriatic acid, which phy- 
sicians of experience recommend. This agent causes such pain that it 
occasions restlessness of the child, and such stout resistance that the use 
of chloroform has been recommended to facilitate its application. The 
pain occurring from it and from the inflammation which it excites doubt- 
less reduces the strength which it is very necessary to preserve. If the 
acid come in contact with the teeth, as it generally will, it injures them 
irreparably, and it sometimes attacks the jaw-bone. Dr. West, who ad- 
vocates the use of the acid (Diseases of Infancy and Childhood, 4th Amer. 
edit., page 467), says: " In one of the cases that I saw recover, the arrest 
of the disease appeared to be entirely owing to this agent, though the 
alveolar processes of the left side of the lower jaw, from the first molar 
tooth backwards, died and exfoliated, apparently from having been de- 
stroyed by the acid." No such result follows the use of the solution of 
sulphate of copper, and of its efficacy I can speak confidently. In one of 
those severe cases in which the disease resulted from scarlet fever, and in 
which there was so much debility that an unfavorable prognosis was made, 
I succeeded in arresting the disease by the use of Dr. Coates's prescription. 
The child recovered with the loss of two teeth and the corresponding por- 
tion of the maxillary bone. From the good effects which I have observed 
from iodoform, as an application for gangrenous vulvitis following measles, 
it has occurred to me that it may also be useful in gangrene of the mouth. 

The application should be made twice a day till the gangrene is arrested 
and healthy granulations appear. 

The gases arising from the gangrenous mass are not only highly offensive 
to others, but they are doubtless injurious to the patient, who is constantly 
inhaling them. To remove the fetor, chlorine or carbolic acid, properly 



DENTITION. 591 

diluted, should be occasionally used between the applications of the sul- 
phate of copper. Labarraque's solution, one part to eight or ten parts of 
water, is an eligible form for its use. When the gangrene is removed, and 
the granulations present a healthy appearance, all danger is usually past 
and convalescence is fully established. Then no energetic topical treat- 
ment is required. A mild stimulating lotion, like the tincture of myrrh, 
as recommended by Dr. Gerhard, suffices, with the aid of tonics and nu- 
tritious diet. 



CHAPTER IV. 

DENTITION. 

The opinion formerly entertained in the profession, and now prevalent 
in the community, that many infantile maladies arise directly or indirectly 
from dentition, is erroneous. Still there are physicians of experience who 
believe that teething is a common cause of certain maladies, especially of 
functional derangements, even of organs remote from the mouth. On the 
other hand, equally good observers, and the number is increasing, almost 
wholly ignore the pathological results of dentition. They say that, as it 
is strictly a physiological process, it should, like other such processes, be 
excluded from the domain of pathology. 

A moment's reflection will show how important it is to understand the 
exact relation of dentition to infantile diseases. Every physician is called 
now and then to cases of serious disease, inflammatory and others, which 
have been allowed to run on without treatment, in the belief that the symp- 
toms were the result of dentition. I have known acute meningitis, pneu- 
monitis, and entero-colitis, even with medical attendance, to be overlooked 
and the symptoms attributed to teething during the very time when ap- 
propriate treatment was most urgently demanded. Many lives are annu- 
ally lost from neglected entero-colitis, the friends believing the diarrhoea 
to be symptomatic of dentition, a relief to it, and therefore not to be 
treated. Such mistakes are traceable to the erroneous doctrine, once 
inculcated in the schools, and still held by many of the laity, that denti- 
tion is directly or indirectly a common cause of infantile diseases and de- 
rangements. 

I shall encleaver to point out what is really ascertained in regard to the 
pathological relations of dentition. 

First dentition commences at the age of about six months and termi- 
nates at the age of two and a half years. The corresponding teeth of the 
two sides pierce the gum at about the same time. The two inferior central 
incisors first appear at about the age of six or seven months, followed, in 
the order in which they are mentioned, by the upper central incisors, upper 



592 DENTITION. 

lateral incisors, lower lateral incisors, the four anterior molars, the four 
canines, and lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight 
by the age of one year. From the age of one year to sixteen months the 
anterior molars appear, from the age of sixteen to twenty -four months the 
canines, and from twenty-four to thirty months the posterior molars. 

This order is not always preserved. Sometimes the upper central in- 
cisors appear before the lower, and sometimes the lower lateral before the 
upper lateral. In rare cases there have been teeth at birth. I have seen 
but one or two infants with such premature dentition. Retarded dentition 
is much more common. Those who have rickets, or are feeble either con- 
stitutionally or by disease, often have no teeth till considerably after the 
usual period. In such the first incisors may not appear till the age of 
twelve months, or even later. 

Pathological Results of Dentition The evolution of the teeth 

is commonly attended by more or less turgescence around the dental bulbs. 
This is greater with some of the teeth than with others. Thus, the superior 
incisors cause more swelling than do their congeners of the inferior jaw. 
The turgescence, although attended by more or less congestion, is physi- 
ological within certain limits, and not a disease. 

But sometimes there is an unusual amount of swelling around the den- 
tal follicles ; the afflux of blood to them is greatly augmented ; they are 
the seat of such a degree of tenderness and pain that the infant is fretful. 
It carries the finger often to the mouth, indicating the seat of its suffering. 
The surface over the follicles presents greater redness than in ordinary 
dentition, and the salivary secretion is considerably increased. There is 
now actual gingivitis. 

Occasionally the inflammation affects a greater extent of the buccal sur- 
face than that lying directly over the follicles, so that most writers speak 
of stomatitis as one of the results of dentition. In a few cases I have 
known such a degree of inflammation over the advancing tooth, that a 
small abscess formed, producing much pain and restlessness, till it was 
opened by the lancet. 

The pathological results of dentition which I have mentioned, though 
they may interfere more or less with the nursing or feeding are not dan- 
gerous. They are easily detected. They result directly from the rapid 
growth and augmented sensibility of the dental follicles. 

There are other supposed accidents of dentition occurring in distant 
parts of the system in consequence of that mysterious relation and inter- 
dependence of organs which exist through the system of nerves. 

Some children, previously to the eruption of the teeth, are affected with 
diarrhoea, occasionally accompanied by irritability of stomach. Certain 
writers have supposed that gastro-intestinal catarrh is present in these 
cases ; others that there is simply a hypersecretion, an increased ac- 



PATHOLOGICAL RESULTS OF DENTITION. 593 

jtivity of the intestinal follicular apparatus, that it is, in other words, one 
of the forms of non-inflammatory diarrhoea. Barrier believes that the 
diarrhoea of dentition depends usually on what he calls a " subinflamma- 
tory turgescence limited to the gastro-intestinal follicular apparatus." He 
believes that, in occasional cases, it is due to defective or altered innerva- 
tion. It would then be analogous or similar to that form of diarrhoea 
which occurs in the adult from the emotions. Bouchut calls the diarrhoea 
of dentition nervous diarrhoea. It is certain, however, that in most cases 
of diarrhoea which are attributed to dentition there are other causes, such 
as unsuitable food, or residence in an insalubrious locality. It is certain, 
as regards city infants, that the chief causes of diarrhoea during the period 
of dentition are strictly anti-hygienic, dentition being quite subordinate as 
a cause, and probably often not operating at all as such. But when, as 
sometimes happens, at each period of dental evolution, the infant is af- 
fected with diarrhoea, the influence of teething is apparent. Such cases 
enable us to see that teething may really sustain a causative relation to 
certain diseases not located in the buccal cavity. 

Among the most common pathological results of difficult dentition, are 
certain affections referable to the cerebro-spinal system. Eclampsia is one 
of the admitted results. Barrier attributes convulsions in the teething in- 
fant to excitement of the nervous system arising from the pain which is 
felt in the gums, and to a determination of blood to the dental apparatus, 
in which afflux the whole vascular system of the head participates. 

In most cases of convulsions occurring during the period of dental 
evolution, a careful examination discloses other causes in addition to the 
state of the gums. Difficult dentition must then be considered, not so fre- 
quently a direct as a co-operating or predisposing cause, producing a sensi- 
tive state of the nervous system, or possibly an afflux of blood to the head, 
of which Barrier speaks, and which, by an additional stimulus, perhaps 
trivial in itself, ends in convulsions. In exceptional instances eclampsia 
occurs mainly from dentition, or, if there are other causes, they are quite 
subordinate. This may happen when several teeth penetrate the gum at 
or about the same time. Infants who are burnt or scalded are very liable 
to clonic convulsions. This is, in fact, the chief danger as regards life 
from such accidents. So, the swollen and tender gum, if several teeth are 
about emerging, may affect the cerebro-spinal system like the bum or 
scald, and produce the same nervous phenomena. Thus, in a case already 
alluded to in the chapter on convulsions, five incisors pierced the gum within 
about two weeks, and in this period there were two attacks of eclampsia 
with an interval of a few days. The attacks were not severe, and the 
most careful examination could discover no other cause than the simul- 
taneous development of so many dental follicles. Previously, and since, 
the infant has been well. 

Dentition sometimes, though rarely, occasions also tonic convulsions. 
38 



594 DENTITION. 

The following case occurred in the practice of Dr. A. S. Church, of this 
city, the history of which he has so kindly communicated, as follows : — 

" H., seven months old, was first visited April 3d, 1863. The patient 
had been fretful for several days, but about daylight on the. morning of 
my first visit it commenced crying, and had not ceased for a moment at 
the time of my visit, 9 A. M. The bowels were somewhat constipated and 
tympanitic ; abdominal muscles very tense. The pain was supposed to be 
in the abdomen, and" a brisk cathartic, to be followed by an anodyne, was 
ordered. Some relief followed, but, on the ensuing and for several con- 
secutive mornings, the pain returned, each day lasting longer, until the 
child only ceased crying while under the influence of a full anodyne. 
The gum over the upper incisors was considerably swollen, hot, and dry, 
but the parents would not consent to have it scarified. For the first 
week there was no fever, no vomiting, and not the least indication that 
the nervous system was suffering. About the 1 Oth the thumbs were noticed 
to be flexed during the attack of pain, and about the 15th the flexors of 
the toes were contracted and the hands were turned backwards and out- 
wards, but only while the child was awake. About the 20th there was 
constant contraction of the flexors of both extremities, with opisthotonos, 
and constant rolling of the head, loss of appetite, progressive emaciation, 
coated tongue, and highly inflamed gums. Consent was, finally, obtained 
to relieve the inflamed gum, and free incisions were made, and the follow- 
ing night the child slept comfortably for three hours without opiates. In 
three days the gums were freely cut again, and the teeth soon made their 
appearance. All symptoms of disease had now ceased, the child became 
playful, and on the 30th the patient was discharged." 

The opinion has been prevalent in the profession, that painful and diffi- 
cult dentition is one of the chief causes of infantile paralysis, but it is now 
commonly admitted that it is only a subordinate or remote cause, if indeed 
it is proper to consider it as a cause at all. (See Art. Paralysis.) 

Some writers express the opinion that acute meningitis occasionally 
results from teething. The facts, however, that are relied upon to prove 
this are uncertain. The occurrence of meningitis during dentition is 
probably in most instances a coincidence. 

Teething less frequently disturbs the respiratory system than either the 
digestive or cerebro-spinal. A cough occurs in some infants at each period 
of dental evolution. It is attended by little expectoration, but appears to 
be associated with, in at least certain cases, an inflammatory turgescence 
of the bronchial mucous membrane. 

Acceleration of pulse is often observed at the time of greatest swelling 
and tenderness of the gum. It subsides with the protrusion of the tooth. 
The febrile movement of dentition is irregular, sometimes presenting a re- 
mittent form, like remittent fever or the fever premonitory of meningitis. 
Eczema and certain other cutaneous diseases are common during dentition, 
but their dependence on it as a cause has not been demonstrated. 

Diagnosis — The accidents of dentition which are located in the mouth 
are easily diagnosticated, except the odontalgia which writers describe, and 



TKEATMENT. 595 

which is not necessarily attended by any perceptible anatomical alteration 
of the gums. Those accidents which pertain to remote and concealed 
organs are usually detected with ease, though it is often difficult to deter- 
mine with certainty their relation to dentition. 

When similar symptoms arise at each epoch of teething, and subside 
with the subsidence of the gingival turgescence, teething must be regarded 
as the cause. Or, if the disease is such as is known to be produced occa- 
sionally by difficult teething, and if, after a careful examination, we can 
discover no other cause, while the gums are swollen, especially over two 
or more advancing teeth, it is proper to refer the malady to dentition. 

It is evident that we must often be in doubt whether the disease which 
we are treating is due at all to the state of the gums, or, if so, whether 
directly or indirectly, or to what extent ; but, as a rule, if any other cause 
is apparent, we may properly regard the influence of dentition as quite 
subordinate. 

Treatment It is obvious that remedial measures in cases of difficult 

dentition must be twofold, namely, those directed to the state of the gums, 
and those designed to relieve the derangements or diseases to which den- 
tition has given rise. If there is diarrhoea, this should be controlled by 
proper remedies, so as to reduce the number of evacuations to two or three 
daily. It is well to state to the friends of the child, who believe that diar- 
rhoea is salutary during the period of teething, that this number is quite 
sufficient, and that more frequent evacuations will endanger the safety of 
the child. 

The nervous affections, as convulsions, require such soothing and de- 
rivative measures as are recommended in our remarks on diseases of the 
nervous system. The bromide of potassium I have found especially useful 
and safe in cases of fretfulness and nervous excitement due to dentition. 
The rational employment of therapeutic measures requires strict attention 
to be given to the causes of disease. Therefore, the physician called to 
treat an ailment, believed to be due to dentition, should not fail to ex- 
amine the state of the gums, and adopt such measures as will mitigate 
the intensity of the cause — in other words, diminish the tenderness if not 
the swelling of the gum. Demulcent and soothing lotions are sometimes 
useful. The infant should be allowed to hold in the mouth an India- 
rubber or ivory ring, which, by pressure on the gum, gives considerable 
relief. 

Mothers will often attempt to " rub through a tooth," as they term it, 
by means of a ring or thimble. This should be discouraged. So great 
friction cannot fail to have an injurious effect, by increasing the swelling 
and inflammation, unless the tooth has already reached the mucous mem- 
brane. 

We come now to a subject which has engaged the attention of many of 
the ablest and most experienced physicians, and in reference to which 



596 DENTITION. 

there is still a difference of opinion among the highest authorities in medi- 
cine. I refer to scarification of the gums. 

The gum-lancet is now much less frequently employed than formerly. 
It is used more by the ignorant practitioner^ who is deficient in the ability 
to diagnosticate obscure diseases, than by one of intelligence, who can dis- 
cern more clearly the true pathological state. Its use is more frequent in 
some countries, as England, under the teaching of great names, than in 
others, as France, where the highest authorities, as Killiet and Barthez, 
discountenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, 
the remark made by Trousseau, that the tooth is not released by lancing 
the gum over the advancing crown. The gum is not rendered tense by 
pressure of the tooth, as many seem to think, for, if so, the incision would 
not remain linear, and the edges of the wound would not unite, as they 
ordinarily do by first intention within a day or two. This speedy healing 
of the incision, unless the tooth is on the point of protruding, is an im- 
portant fact, for it shows that the effect of the scarification can only last 
one or two days. The early repair of the dental follicle is probably con- 
servative so far as the development of the tooth is concerned. It may 
help us to understand how r active, how powerful, the process of absorption 
is, if we reflect that the roots of the deciduous teeth are more or less ab- 
sorbed by the advancing second set, without much pain or suffering from 
the pressure. If the calcareous particles of the teeth are so readily ab- 
sorbed, what is the foundation for the belief that the fleshy substance of 
the gum is absorbed with such difficulty ? Too much importance has evi- 
dently been attached to the supposed tension and resistance of the gum in 
the process of dentition. 

Follicles in the period of development are especially liable to inflamma- 
tion. We see this in the follicular stomatitis and enteritis, so common 
when the buccal and intestinal follicles are in the state of most rapid 
growth. Does not this law in reference to the follicles hold true of those 
by which the teeth are formed, so that the period of their enlargement 
and greatest activity, which corresponds with the growth and protrusion 
of the teeth, is also the period when they are most liable to congestion and 
inflammation ? This fact affords a better explanation of the frequency of 
the so-called laborious or difficult dentition than that it is due to the re- 
sistance which dental evolution encounters from the gums. 

If there are no symptoms except such as occur directly from the swell- 
ing and congestion of the gum, the lancet should seldom be used. The 
pathological state of the gum which w T Ould, without doubt, require its use, 
is an abscess over the tooth. As to symptoms which are general or refer- 
able to other organs, as fever and diarrhoea, the lancet should not be used 
if the symptoms can be controlled by other safe measures. All co-operat- 



SECOND DENTITION. 597 

ing causes should first be removed, when in a large proportion of cases the 
patient will experience such relief that scarification can be deferred. 

If the state of the infant is one of immediate danger, as in convulsions, 
and it is not quickly relieved by the ordinary remedies, scarification may 
not only be proper but required to insure safety. For in such cases all 
measures, provided they are safe and simple, which can possiMy give 
relief should be employed without delay. But I can recall to mind only 
two accidents of dentition which would be likely to be benefited by scarifi- 
cation, namely, suppurative inflammation in the dental follicle and convul- 
sions. But since the bromide of potassium has come into use as a nervous 
sedative, and as an efficient remedy for clonic convulsions, scarification of 
the gums is much less frequently required, for even severe eclampsia com- 
monly yields to this medicine, if the condition of the bowels is attended 
to. Cutting the gums is now abandoned as a means of relief in infantile 
paralysis, for this malady is known to be due to other causes than den- 
tition. 

Second Dentition. 

The fact is well established, though often overlooked in practice, that 
second dentition occasionally deranges the functions of organs, and gives 
rise to pathological symptoms. Rilliet and Barthez mention particularly 
neuralgic pains, rebellious cough, and diarrhoea, as effects which they have 
observed. Rilliet relates the case of a girl, eleven years old, who had a 
very obstinate and protracted cough, the paroxysms lasting often half an 
hour to one hour. This cough immediately and permanently disappeared 
when the molars pierced the gums. 

Dr. James Jackson, in his Letters to a Young Physician, says: "I have 
seen persons between twenty and thirty years of age much affected by a 
wisdom tooth not yet protruded, and distinctly relieved by cutting the gum. 
But I think the most common period of suffering from the second den- 
tition is from the tenth to the thirteenth year. The most characteristic 
affections are wasting of flesh and nervous diseases. The boy loses his 
comeliness, and his complexion is less clear, while emaciation takes place 
in every part, though mostly, perhaps, in the face. The nervous symp- 
toms are various, but the most common are a change in the temper and 
a loss of spirits. With these there is some loss of strength. The patient 
is unwilling to engage in play, and soon becomes tired wdien he does do it. 
Among the distinct symptoms which are not uncommon, I may mention 
pain in the head and in the eyes. The headache is not commonly severe, 
but it is such as inclines the patient to keep still. The eyes are not only 
painful, but are often affected with the morbid sensibility to which these 
organs are subject. I have known boys truly anxious to pursue their 
studies obliged to give them up on this account; and these, not having the 
disposition to play, will of choice pass the day with their mothers, and in- 



598 CATARRHAL PHARYNGITIS. 

crease their troubles by the want of air and exercise. Nervous affections 
of a more severe character are sometimes manifested." 

Whether the symptoms which have been. attributed to second dentition 
have always been due to this cause, is questionable. Practically, how- 
ever, it matters little, whether we recognize dentition as the cause, or 
assign something else. Hygienic and medicinal measures to improve the 
general health will usually suffice to relieve the patient. Elsewhere I have 
related the case of a boy, of nervous temperament, about seven years old, 
who recovered immediately from a cough which had lasted for several 
weeks, by taking a mixture of iron and nitric acid. Many do well without 
medicine, simply by hygienic measures. Dr. Jackson says : " The remedies 
which I have found most useful are as follows : First, a relief from study 
or from regular tasks, yet using books so far as they afford agreeable 
occupation or amusement. Second, exercise in the open air, preferring 
the mode most agreeable to the patient, and in more grave cases the 
removal from town to country." 



CHAPTER V. 

CATARRHAL PHARYNGITIS, PERIPHARYNGEAL ABSCESS, OESOPHAGITIS. 

Children of all ages are liable to inflammation of the pharynx. In 
its mildest form it often, doubtless, escapes detection in 'the young infant. 
In older patients it is revealed by pain in swallowing solid food, and more 
or less tumefaction below the ears, apparent to the sight. It is said to be 
less frequent in infancy than in childhood. In the adult, and in children 
over the age of four or five years, inflammation of the pharyngeal surface 
is often confined to the portion of membrane which covers or immediately 
surrounds the tonsils. It occurs in connection with inflammation of these 
glands. But in infancy and early childhood this limitation is compara- 
tively rare. Catarrhal inflammation of the fauces at this age is ordinarily 
general, the tonsils participating in the morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in 
measles, scarlet fever, bronchitis, croup, pneumonitis, and occasionally in 
other affections. As these diseases are common, physicians are oftener 
called to treat patients who have the secondary form than the primary. 
Rilliet and Barthez met eighty-three secondary to sixteen primary cases. 

Anatomical Characters. — The pathological anatomy of pharyngitis 
is ascertained by depressing the tongue and inspecting the fauces. The 
faucial surfaces is seen to be redder than in health, with more or less 
swelling, according to the intensity of the inflammation. In the primary 



CAUSES — SYMPTOMS. 599 

inflammation the color is commonly bright red, almost like that of arterial 
blood. If, on the other hand, the inflammation occurs in connection with 
a constitutional malady, the hue is apt to be darker. In grave cases of 
scarlet fever or measles, it is sometimes even livid, indicating a vitiated 
state of the blood, a condition of real danger. The tonsils are tumefied so 
as to project, though not to the extent which we often observe in the adult. 
They are then less firm than in the normal state. The follicles of the 
throat are enlarged and active, pouring out a muco-purulent secretion. 
This is sometimes seen in a layer over the tonsil or the posterior portion 
of the fauces. In a case of primary pharyngitis examined after death by 
Rilliet and Barthez, the tonsils were softened, infiltrated with pus, and 
slightly enlarged. A layer of bloody mucus lay on the pharyngeal sur- 
face, w r hich was dark-red, thickened and glandular. The submaxillary 
glands were also swollen and somewhat softened. 

If the inflammation is intense, the deep-seated portions of the tonsils 
become involved, and even sometimes the adjacent connective tissue. In 
such cases, by applying the fingers in the hollows below the ears, the ton- 
sils can be felt. 

Causes. — The usual cause of primary pharyngitis is exposure to cold. 
It also occasionally occurs from the use of drinks too hot or containing 
some irritating substance, I have met it in the most intense form caused 
by swallowing boiling water, and, in one case, from acetic acid taken 
through mistake. When it occurs in the eruptive fevers, it is usually part 
of a more extensive phlegmasia, in which the buccal and perhaps laryngeal 
and nasal surfaces participate. 

Symptoms. — Fever, with thirst and loss of appetite, is common, and is 
usually proportionate, in intensity, to the extent and severity of the in- 
flammation. At first there is dryness of the faucial surface, and this is 
succeeded by a more or less abundant viscid secretion. Swallowing is 
painful, except in mild cases. The muscles of the anterior half arches, 
which by their contraction, close the opening from the pharyngeal to the 
buccal cavity, and those of the posterior arches, which close the opening 
to the nasal cavity, both w T hich sets lie a little under the mucous mem- 
brane, are often so infiltrated with serum that their contractile power is 
diminished, and if the same happen with the constrictor muscles, which 
carry downward the food, swallowing becomes difficult, and in the attempt, 
more or less of the ingesta is apt to return into the mouth, or enter the 
nostril. During health the air passes through the nostrils in the pro- 
nounciation of two letters only, namely, N and M, but in severe pharyn- 
gitis, in consequence of the swelling, and the impairment of the action of 
the muscles concerned in speech, the air passes through the nostrils with 
the utterance of many words, producing the nasal tone of voice. Some- 
times the inflammation traverses the Eustachian tube to the middle ear, 



600 CATARRHAL PHARYNGITIS. 

causing earache, which may be relieved by the escape of pus down the 
tube, or by perforation of the drum into the external ear. 

The breath is foul, but not fetid ; the respiration normal, or but slightly 
accelerated ; there is commonly no cough, but it is sometimes present, due 
to the extension of the inflammation to the upper part of the larynx, or 
to the collection of mucus around the aperture of the glottis. In most 
cases of pharyngitis there is a light fur upon the tongue, and stomatitis of 
a mild grade is present, as shown by redness of the buccal surface, and an 
increased mucous secretion. 

Chronic pharyngitis, which is so common in adults, and which is pro- 
duced in some by gastric derangements, and in others by excessive 
smoking, or the prolonged use of intoxicating drinks, and in others, still, 
by the syphilitic or mercurial cachexia, is comparatively rare in children. 

Prognosis In mild cases of pharyngitis convalescence commences 

within a week. If the inflammation is dependent on a constitutional 
malady it may continue considerably longer, especially if the glands of 
the neck, and the connective tissue are much involved. The prognosis in 
secondary pharyngitis is less favorable than that of the primary form. In 
fatal cases there is usually a vitiated state of the blood, either from the 
coexisting constitutional disease, or from previous cachexia. 

Pharyngitis may, however, become dangerous from complications to 
which it gives rise. The proximity of the inflammation to the brain, or 
its effect upon the cerebro-spinal axis through the medium of the nerves, 
sometimes gives rise to clonic convulsions. In a recent case of primary 
pharyngitis in my practice, repeated and violent convulsions occurred in 
an infant, about one year old, from this cause. They commenced at the 
inception of the inflammation, and constituted the only real danger. 
Pharyngitis may interfere materially with nutrition in consequence of the 
dysphagia, but in most cases of primary pharyngitis this symptom does not 
continue sufficiently long to endanger the life of the patient. In grave 
constitutional affections, as scarlet fever, the difficulty of swallowing, and 
the consequent innutrition, augment the danger. As regards, therefore, 
the prognosis in catarrhal pharyngitis, whether primary or secondary, it 
may be stated as a rule, that it is not, per se, a fatal disease, but is only 
so from complications, or from aggravating the primary malady with which 
it is associated. 

Diagnosis This is not difficult provided that attention is directed to 

the throat; but the physician often fails to discover it at his first visit, from 
neglecting to examine this part. In many cases the local symptoms are 
not well-marked, and in the absence of these the febrile reaction may at 
first be referred to some other cause than the true one. Inspection not 
only reveals the presence of inflammation, but enables us to determine 
whether it is simple pharyngitis, or diphtheritic, or ulcerative. In some 
instances, simple pharyngitis resembles the diphtheritic, from the presence 



TREATMENT. 601 

of confervoid growths upon the inflamed surface, usually the leptothrix 
buccalis. The differential diagnosis is based on the easy removal and 
soft pultaceous character of the confervas, and the appearance under the 
microscope. 

Treatment Mild cases of simple pharyngitis require little treatment. 

With moderate counter-irritation over the throat, and the use of laxative 
medicines, the inflammation soon subsides. The linimentum camphorae 
may be occasionally rubbed over the throat, and retained upon it by flan- 
nel. The effect is increased by the application, once or twice daily, of 
mustard or tincture of iodine, or by adding to the liniment one-fourth or 
one-third of its quantity of turpentine. 

Some children seem to be most relieved by a muslin compress fre- 
quently wrung out of cool water, and retained upon the neck by a dry 
cloth bandage. Frequently rubbing the neck with warm oil or camphor- 
ated oil, and binding upon it a rind of salt bacon, are popular modes of 
treatment, and no doubt are productive of benefit. 

In the severe forms of this inflammation, occurring independently of 
any other disease, more acute measures are sometimes required. 

If there is stupor or restlessness, with unusual heat of head, and start- 
ing or twitching of the limbs which threaten convulsions, two to five 
grains of the bromide of potassium given every two or three hours, pro- 
duce an excellent calmative effect. 

Diaphoretics and sometimes cardiac sedatives are also indicated, such 
as liquor ammoniae acetatis, spiritus astheris nitrosi, ipecacuanha, and 
aconite. Medicines of this kind may be variously combined according to 
the age and condition of the patient, and the severity of the. disease. 

As the symptoms abate, the intervals between the doses may be in- 
creased. 

In cases of much tenderness and dysphagia great relief is often obtained 
by emollient poultices applied over the throat. 

Topical treatment of the pharynx is recommended by most authors. 
Eilliet and Barthez use for this purpose nitrate of silver or powdered 
alum. The former has been most employed by physicians. It may be 
applied in the proportion of ten grains to the ounce two or three times 
daily. I prefer the following mixture, used with the hand atomizer every 
two to four honrs : — 

R. Acid, carbolic, gtt. xxxij ; 
Potas. clilorat., giij ; 
GTycermae, §iij ; 
Aquse, §vj. Misce. 

This can of course be used as a gargle by those old enough, or more 
continuously by the steam atomizer, if diluted with twice as much water. 

The treatment of secondary pharyngitis will be described in connection 
with the treatment of the diseases which it complicates. Suffice it here 



602 PERI-PHARYNGEAL ABSCESS. 

to say that this form of inflammation must not be treated by those de- 
pressing remedies which are useful in certain cases of idiopathic pharyn- 
gitis. 

Peri-Pharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess occa- 
sionally forms between the pharynx and vertebral column (retro-pharyn- 
geal), or upon the side of the pharynx in the submucous connective tissue. 
This constitutes a disease which is apt to be fatal, but which can ordina- 
rily be promptly relieved by the surgeon. 

Yet, if we look over the records of peri-pharyngeal abscess, we shall 
see that in a large proportion of fatal cases, the disease was supposed to 
be something else, and so treated until its nature was revealed by post- 
mortem examination. The most complete monograph on this malady 
with which I am acquainted was published by Dr. Allin, of this city, in 
the JV. Y. Jour, of Med. for November, 1851, under the title of retro- 
pharyngeal abscess. To this paper I am largely indebted for facts. 

Age — Cause This abscess may occur at any age, but it is most 

common in infancy and childhood. It is more frequent in the first two 
years of life than at any other period. Of the cases collated by Dr. Allin, 
in w r hich the age is stated, twenty were under ten years, and twenty-one 
over this age. The abscess occurs in some patients from caries of the 
vertebral column, and, in others, from inflammation developed in the 
connective tissue or small lymphatic glands lying immediately outside the 
pharynx, or from a catarrhal pharyngitis. Whichever the cause, there is 
usually a scrofulous or reduced state of system. 

Writers describe two kinds of peri-pharyngeal abscess, the primary and 
secondary. This distinction is based on the fact, whether or not the 
inflammation which leads to the abscess is dependent on an antecedent 
pathological state. 

In the primary form the cause is usually atmospheric, or it is some 
irritating substance which has been swallowed, and which, lodging in the 
pharynx, produces phlegmonous pharyngitis. 

The cause is mentioned in twenty cases of the primary form, collated 
by Dr. Allin, as follows: exposure to cold, ten cases ; lodgment of bone 
in pharynx, eight cases ; bloAv with a fencing-foil, one case. In the last 
case the button of a fencing-foil passed through the right nostril into the 
pharynx. 

The secondary form occasionally occurs after measles and scarlet fever. 
The inflammation of the pharynx, common in those diseases, extends to 
the subjacent connective tissue, and, aided by the discrasia of the patient, 
becomes suppurative. Such cases have been observed by Rilliet and 
Barthez. The most common cause of the secondary form is, however, 
caries, occurring in the cervical vertebrae. 



ANATOMICAL CHARACTERS — SYMPTOMS. 603 

When thus occurring it is similar, both as regards cause and nature, to 
lumbar abscess. It would follow the same chronic course, and would 
properly be described in connection with it, were it not for its proximity 
to the air-passages, which renders the symptoms so urgent and dangerous. 
In a few recorded cases the abscess was a sequel of erysipelas. In nine- 
teen cases of secondary abscess, in Dr. Allin's collection, the cause is 
assigned as follows : erysipelas of face, two ; inflammation following a fall 
upon the inferior maxilla, one ; after cerebritis, one ; syphilis, four ; caries 
of the cervical vertebra, six ; scrofula, five. 

The plausible opinion is expressed by Mr. Fleming (Dublin Journ. of 
Med. Sci., vol. xviii.), that the suppuration begins, in a large proportion 
of cases, in the small lymphatic glands which lie in the connective tissue 
external to the pharynx. The late Prof. Geo. T. Elliot has recorded the 
case of an infant of seven months (Obstet. Clinic, N. Y., Appleton & Co., 
1868) in whom peri-pharyngeal abscess immediately followed, and was 
apparently due to parotiditis. 

In rare instances the abscess, or the local disease which leads to it, 
appears to exist from birth. Thus, Dr. E. O. Hocken relates, in the 
Prov. Med. and Surg. Journ., 1842, the history of an infant who died at 
the age of nine weeks. It had always, when taking the breast, thrown 
back its head as if nearly suffocated. The walls of the abscess were thick 
and firm, described by the writer as cartilaginous. Occasionally there is 
no apparent cause of the abscess, except the strumous or cachectic state. 

Anatomical Characters The seat of the abscess is not the same 

in all cases. The swelling can ordinarily be seen on examining the fauces, 
but occasionally it is so low as to be really peri -oesophageal, and, therefore, 
invisible. The size of the abscess varies ; sometimes it is large, pressing 
inward the wall of the pharynx even against the velum palati and into 
the posterior nares, if the abscess have a high location, or, if lower, against 
the larynx, so as to embarrass respiration. Sometimes the abscess is so large 
or has such lateral extension that there is external swelling along the side 
of the neck. In a few cases on record the pus, instead of being discharged 
into the pharynx, made its way down the neck between the muscles and 
the connective tissue to the pleural cavity, which it entered, producing 
fatal pleuritis. 

The walls of the abscess have been found in a different state in different 
cases. Sometimes the sac, at the projecting point, is so thin that it seems 
as if there might have been a spontaneous cure, could life have been pre- 
served a few hours longer. In other cases the sac is so thick and firm 
that its rupture, for many days, would be impossible. 

Symptoms — The precursory symptoms differ in different cases, accord- 
ing to the nature of the cause, whether it be phlegmonous pharyngitis or 
simply adenitis or vertebral caries. If the abscess proceed from caries, it 



604 PERI-PHARYNGEAL ABSCESS. 

is preceded by deepseated pain, greatly increased by movements of the 
head, and probably by induration along the sides of the vertebra. 

The patient with this disease is restless, his mouth hot and dry ; tongue 
furred ; deglutition more or less difficult. Sometimes after suppuration has 
occurred there are alternations of rigors and fever. The symptoms indi- 
cate approximately the seat of the inflammation, but on examination we 
do not find that degree of redness of the mucous surface which we had 
been led to expect. The tissues which are chiefly involved in the inflam- 
mation, being submucous, are hidden from view. We observe redness of 
the pharynx, but it is disproportionate to the intensity of the symptoms. 
Sometimes there is a sensation of chilliness through the entire period of 
the abscess, though greater at one time than at another, and occasionally 
convulsions occur, especially in young infants. In ordinary cases embar- 
rassment of respiration occurs early, and is the cause of the chief danger. 
It becomes more and more marked as the abscess increases. It is noticed 
both during inspiration and expiration. The dysphagia also increases, 
sometimes to such a degree that drinks are taken with difficulty, and solid 
food refused. The respiratory symptoms bear considerable resemblance to 
those in protracted laryngitis, for which this disease has been mistaken. 
While the respiration becomes impeded or whistling, the voice is also 
feeble or indistinct, from the pressure of the tumor. 

But the symptoms described above are not all present in every case. 
They vary according to the size and location of the abscess, whether it be 
high or low, posterior or lateral. I have met the disease in a child old 
enough to express its subjective symptoms, in whom there was little or no 
dysphagia, and others report similar cases. When the tumor has attained 
such a size as to produce well-marked symptoms and jeopardize the life of 
the patient, it, or a part of it, can ordinarily be seen on depressing the 
tongue, but usually its location and condition can be better ascertained by 
exploration with the finger. The dyspnoea increases as the abscess en- 
larges, and, after a time, unless it bursts spontaneously or is opened by the 
surgeon, imperfect oxygenation of the blood results. In some patients 
paroxysms of dyspnoea occur, so as to threaten immediate suffocation ; 
coughing or attempts to swallow induce these paroxysms, and the patient 
is forced to remain in an erect or semi-erect posture. The tongue is pro- 
truded, the head thrown back, the pulse is frequent and rapid, the limbs 
become livid and cool, and finally death occurs from dyspnoea. Occasionally, 
when death seems inevitable, the abscess breaks during the struggles of the 
child, and the patient is restored to health. In rare cases the result is dif- 
ferent. The trachea and bronchial tubes are deluged by the purulent dis- 
charge, and immediate suffocation occurs. The following was an example : 
In May, 1871, a boy two years and five months old, was brought to the class 
at Bellevue, who had had the symptoms of an abscess for three months. 
The head was carried on one side, its rotation caused pain, and a laryngeal 



SYMPTOMS. 605 

rale accompanied respiration. The upper part of the tumor could be de- 
tected by the finger, but, on account of its low location, it was impossible 
to open it with the bistoury. The temperature was 103°, pulse 156. The 
case was kept under observation, but in a few days the dyspnoea suddenly 
became so urgent that death was imminent, when the attending physician 
of the class, Dr. Swezey, broke the abscess with his finger, and pus was 
ejected on the floor ; death, however, occurred almost immediately. 

A correct appreciation of the symptoms and the nature of peri-pharyn- 
geal abscess will be best obtained by relating a case. I select the follow- 
ing from the Trans, of the Lond. Pathol. Soc, Oct. 20, 1846 : — 

A female infant died at the age of seven months, having had difficult 
breathing three weeks, and extreme dyspnoea during the last days of life. 
The dyspnoea was constant, and was aggravated by mental excitement, by 
movements of the body, and by exposure to cold. During the paroxysms, 
a peculiar, croupy sound accompanied inspiration. There was no dyspha- 
gia through the entire sickness, and death occurred from apnoea. 

The sac of the abscess was of the size of a pigeon's egg, and was situated 
between the upper cervical vertebrae and the back of the pharynx. The 
abscess was flattened in front, so as not to cause any decided prominence 
of the wall of the pharynx. From the sac a second small cyst extended 
forwards, forming a nipple-like swelling in the pharynx, which completely 
closed the orifice of the glottis. Its aperture of communication with the 
body of the abscess admitted the point of the little finger, and the whole 
swelling was freely movable and perfectly translucent at its extremities 
and sides. The abscess might have been easily punctured, with probably 
the preservation of life. 

The duration of this malady is very different, according to the severity 
of the inflammation, the rapidity with which the abscess enlarges, and the 
direction which it points. A lateral or downward extension is not so im- 
mediately dangerous to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascer- 
tained, and most writers, in determining its duration, compute from the 
first appearance of symptoms which are referable to the pharynx. Dr. J. 
Bryne relates, in the Amer. Journ. of Med. Sci., 1838, a fatal case in 
which the disease had apparently continued only about one week. The 
patient was an infant one year old, and its death was from apnoea. The 
abscess was large, extending from the base of the skull to the thorax, and 
pressing both on the larynx and trachea. M. Besserer (Archiv Gen. de 
Med., 1840) gives the history of an infant four months old, who died in 
the same way after thirteen days. An infant nine months old, whose case 
was published by Dr. W. C. Worthington, in the Prov. Med. and Surg. 
Journ., 1842, lived nine days. The abscess occurred from exposure to 
cold ; the patient was treated for croup, and died from suffocation. The 
anterior wall of the abscess was very thin. Since the first edition of this 



606 PERI-PHARYNGEAL ABSCESS. 

book was published, I have met four patients with this disease in whom 
the pus was evacuated when the dyspnoea had become urgent. In two the 
symptoms indicated a continuance of the disease from two to four weeks, 
and in the third case four months. The fourth case is interesting on ac- 
count of the short duration of the severe symptoms. The following is the 
record of it: M. E., aged 7 months, female, nursing, inmate of the New 
York Foundling Asylum, was observed to have difficult breathing for 
the first time, on March 28, 1875. Since about March 8, some swelling 
had been noticed along the side of the neck, but it gave rise to no marked 
symptoms and she had not seemed ill, till the obstruction in the respiration 
commenced. At my visit on the evening of the 28th, the infant was 
pointed out to me as in a dying condition. She was lying in a state of 
stupor, pallid, and gasping for breath, with a temperature of 103°, and 
very feeble pulse, numbering about 200 per minute. On carrying the 
finger into the throat an abscess could be readily detected, situated in the 
walls of the pharynx on the left side posteriorly. This was easily opened 
by a curved bistoury, around which adhesive plaster was wound to within 
half an inch of the point. The breathing immediately began to improve. 
On the following day the infant was playing in the mother's lap, with a 
pulse of 140, but a normal temperature. With the use of cod-liver oil 
and the syrup of the iodide of iron, its health was soon fully restored. 

When the abscess grows slowly, and presses lightly on the air-passages, 
the case may continue for months. Such a one was observed by Professor 
Willard Parker. ( Allin.) This infant was one year old ; it suffered from 
pharyngeal symptoms nine months, was treated for tonsillitis, and death 
occurred as usual from apncea. The abscess was two inches long, and there 
was no disease of the vertebrae. The same surgeon saved the life of an- 
other patient four years old, in whom the disease was protracted, by punc- 
turing the abscess ; and Professor Post, of this city, also treated success- 
fully a case which had continued three months. (Allin.) 

Diagnosis — The diagnosis of this disease is ordinarily easy, provided 
that the physician examine carefully and bear in mind the occasional 
occurrence of such an abscess. In a large proportion, how r ever, of the re- 
corded fatal cases, the true nature of the disease was not recognized during 
life. Especially is the diagnosis difficult when the cerebro-spinal system 
is early implicated, and symptoms arise which divert attention from the 
throat to the brain. 

The maladies with which peri-pharyngeal abscess is most frequently con- 
founded are laryngitis and simple but severe pharyngitis. From laryn- 
gitis, for which it has been most frequently mistaken, it may be distin- 
guished by the dysphagia and by the character of the initial symptoms. 
In laryngitis there is usually the peculiar cough from the first or very 
early, while in abscess there is an initial period of several days or even 



PROGNOSIS — TREATMENT. 607 

weeks before respiration is materially affected. This is the period of in- 
flammation which precedes suppuration. 

In abscess pressure of the larynx backward is badly tolerated, greatly 
increasing the dyspnoea, while in pharyngitis and croup this effect is not so 
marked. In abscess the horizontal position aggravates the dyspnoea, but 
not in pharyngitis and croup. The character of the voice will also aid in 
diagnosticating abscess from laryngitis, since in the former it is apt to be 
nasal, and in the latter hoarse or whispering. The decisive test is afforded 
by inspection and digital exploration. The tumor is seen, or, if situated 
too low to be seen, is felt, upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the cerebro- 
spinal system, as by convulsions, the priority of the pharyngeal symptoms 
will serve to aid in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should employ digital examination. The finger 
will often detect fluctuation when no evidence of an abscess or uncertain 
evidence is presented to the eye. 

Prognosis With proper treatment the result is usually favorable, but, 

if the disease is not recognized, many die. In Dr. Allin's cases, of those 
under the age of twelve years nine died, while ten recovered by the open- 
ing of the abscess by the lancet, trocar, or finger, and one by its sponta- 
neous rupture. 

If the abscess is due to disease of the spinal column, death may occur 
immediately after the sac is opened, the caries of the intervertebral carti- 
lages producing, according to Dr. Allin, dislocation of the vertebree. Death 
may also occur, though rarely, from pleuritis, in consequence of the burst- 
ing of the abscess into the pleural cavity. Even in caries, if the sac is 
properly opened, and if need be reopened, recovery is possible, as in a case 
treated by Prof. Post. 

Treatment — The proper treatment of peri-pharyngeal abscess is sim- 
ple, consisting in breaking or puncturing the sac by the finger, the lancet, 
bistoury, or pharyngotome. Each method has been successfully employed. 
In the majority of cases the proper way to open the abscess is by the 
ordinary curved scalpel or bistoury, which should be covered by a strip 
of adhesive plaster to within a half inch of the point. If the abscess is 
post-pharyngeal, it should be opened in the median line. A single in- 
cision suffices to evacuate the pus. If the abscess points or is elastic, there 
is little danger of wounding any important vessel or producing dangerous 
hemorrhage if the operation is properly performed. It may be necessary 
to open the abscess more than once, as in a case reported by Dr. Post, 
and another which I saw with Dr. Livingston, of this city. In certain 
cases, when the knife can not be readily employed, the abscess may be 
opened by pressure with the finger nail or the edge of a teaspoon. 

Patients with this disease ordinarily require constitutional treatment, 



608 (ESOPHAGITIS. 

especially the use of tonics, ferruginous and vegetable. The citrate of 
iron and quinine, the citrate of iron and ammonia, and in strumous cases 
the syrup of the iodide of iron with cod-liver oil, are eligible prepara- 
tions. Nutritious diet and often alcoholic stimulants are required. 

(Esophagitis. 

Disease of the oesophagus in infancy and childhood is comparatively 
rare, inflammation being the most frequent affection of this portion of the 
digestive tube in these periods, and, indeed, the only one which claims 
attention. It is most common in infants under the age of three or four 
months, who are deprived of the breast-milk, and are given a diet which 
is with difficulty digested, and perhaps taken too hot or too cold. It is, 
therefore, most common in foundling hospitals. I have frequently observed 
it in the Infant's Hospital, and the Nursery and Child's Hospital, of this 
city, chiefly at the autopsies of bottle-fed infants, under the age of six 
months, whose symptoms had indicated disease or derangement of the 
digestive function. Many of them had diarrhoea^ and died in a state of 
emaciation. Oesophagitis in these cases was associated with simple or 
gangrenous stomatitis, thrush, or with gastritis or entero-colitis. Some- 
times all these inflammations coexisted. In a few cases the confervoid 
growth of thrush had extended from the mouth to the oesophagus. It 
occurred in small hemispherical masses, scarcely as large as a pin's head. 
Swallowing corrosive or strongly irritating substances, as the acids or alka- 
lies, is an occasional cause of oesophagitis, the irritant at the same time 
producing stomatitis and gastritis. 

Anatomical Characters The inflamed surface sometimes presents 

a uniformly injected appearance. Usually, however, there is greater 
intensity of inflammation in streaks or patches than over the surface 
generally. I have frequently observed at autopsies a greater degree of 
inflammation in the lower than upper half of the oesophagus, even when 
the infant had stomatitis at the time of death. 

Oesophagitis occurring from faulty regimen or anti-hygienic conditions 
is not accompanied by as much thickening of the walls of the tube as often 
occurs in some other portions of the digestive canal, as, for example, in the 
colon. Diphtheritic inflammation of the oesophagus is accompanied by so 
great infiltration of the mucous membrane and underlying connective 
tissue that I have seen the oesophageal walls three or four times the 
normal thickness. 

Occasionally ulcerations of the oesophageal mucous membrane are ob- 
served in the lower part of the tube, and Billard describes the ulcerative 
form of oesophagitis. At the first autopsies at which I observed these 
ulcers, I supposed that they were pathological, and indicated a severe 
grade of inflammation ; but a more extended observation has convinced 
me that they are usually post-mortem, and are not at all dependent on in- 



INDIGESTION'. 609 

flammation of the oesophagus. The solvent power of the gastric juice not 
only causes ulceration in the stomach, but entering the oesophagus may 
and not infrequently does produce a solvent action on the mucous tissue 
there. At the meeting of the London Pathological Society, March 4th, 
1852, Dr. Graily Hewitt presented a specimen in which the gastric juice 
had not only eaten entirely through the coats of the oesophagus an inch 
above the stomach; but had even attacked the left lung. Over the age of 
six months inflammation of the oesophagus is rare. 

The symptoms of oesophagitis, in those young and emaciated infants in 
whom it ordinarily occurs, are not well-pronounced. Pain in deglutition, 
or tenderness on pressure over the oesophagus, if present, is ordinarily not 
appreciable. Xor have they seemed to me to vomit oftener than other 
infants of this class who suffered from indigestion and gastro-enteritis, 
without oesophagitis. It is, therefore, difficult to diagnosticate oesophagitis 
in them. It is, according to my observation, oftener present than absent 
in spoon-fed infants of three months or under who have persistent stoma- 
titis and entero-colitis. 

Treatment In the oesophagitis of foundlings and ill-nourished infants, 

which arises, as has been stated, from faulty regimen, no treatment is re- 
quired apart from that designed to relieve the stomatitis or entero-colitis 
with which it occurs. Attention must be directed mainly to the diet and 
hygienic management. The remedial measures are more fully detailed in 
our remarks on entero-colitis. Oesophagitis produced by swallowing cor- 
rosive or highly irritating substances requires the same treatment as in the 
adult, namely, poultices, demulcent drinks, etc. 



CHAPTER YI. 



INDIGESTION, CONGESTION OF STOMACH, GASTRITIS, FOLLICULAR 
GASTRITIS, DIPHTHERITIC GASTRl'i IS, POST-MORTEM DIGESTION, 
SOFTENING. 

Indigestion is more common during infancy than in any other period 
of life. While the digestive organs in the adult easily assimilate a great 
variety of food, it is necessary for the well-being of the infant that its diet 
be simple and carefully prepared. Departure from this rule leads to indi- 
gestion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the 
digestive function less frequently disordered, and indigestion presents few 
peculiarities to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive process 
39 



610 INDIGESTION. 

is ordinarily well performed, but, from some temporary derangement of 
system or error of diet, an acute attack of indigestion occurs. Hence, 
two forms of this ailment may be described : first, acute, referring to 
temporary attacks ; secondly, chronic, referring to the habitual state. 

Causes The causes of indigestion are twofold : first, the condition of 

the digestive function independently of the aliment ; secondly, the un- 
wholesome or improper character of the ingesta. Anything which lowers 
the vital powers may be a predisposing cause of indigestion, by impairing 
the function of the organs which assimilate the food. Impure air and 
personal uncleanliness, protracted hot weather, and previous disease, are 
among the common predisposing causes. The strong country child can 
thrive upon a diet which, given to the more feeble child of the city, would 
produce deleterious results. During the summer months it often happens 
that an infant in the city cannot digest properly any food given to it 
except the mother's milk ; and from this results much of the infantile 
sickness and mortality which make this season of the year so much 
dreaded by parents. There is a natural difference in children, as regards 
liability to disordered digestion. Some do well upon a diet which given 
to others similarly situated occasions vomiting, gastralgia, and flatulence. 

In the majority of cases of indigestion, however, the fault does not exist 
in the child. It is fed too often or irregularly, or upon a diet that is un- 
wholesome, or indigestible. It is well known that the milk of the mother 
or the wet-nurse is liable to changes which render it for the time unsuitable 
for the infant. Her food may be of such a quality, or her mind so ex- 
cited, or some function of her system so disordered, as to effect a temporary 
change in the constitution of the milk. The occurrence of the catamenia, 
or of a gestation, in mothers who are suckling, not infrequently produces 
this unfavorable result. 

Indigestion is most common in those infants who, deprived of the mother's 
milk, are intrusted to wet-nurses, or fed from the bottle. The milk of the 
wet-nurse, from not agreeing with the age of the infant, from irregularity 
in her mode of life, from the acescent nature of her food, or from other 
causes which are not appreciable, may disagree with the infant, and be 
imperfectly digested. 

The most common cause of indigestion in the infant is artificial feeding. 
This, in the cities, is productive of a great amount of gastric and intestinal 
derangement and disease. The younger the infant, the less frequently 
does it thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, whether 
cow's or goat's milk, or farinaceous substances be used, there is seldom that 
healthy nutrition which is observed in infants who receive the natural ali- 
ment. The " swill milk" in common use among the poor families of this 
city is totally unfit for the feeding of infants, and is apt to cause flatu- 
lence, acidity, and indigestion. Acute indigestion occurs in children of 



SYMPTOMS. 611 

any age from food unsuitable in quality or quantity, which produces gas- 
tralgia and other symptoms to be detailed hereafter. Those who suffer 
habitually from mal-assimilation are especially liable to such acute at- 
tacks. 

In the period of childhood, chronic indigestion is much less frequent 
than in infancy, but children are, perhaps, more subject than infants to 
the acute form. This is induced by ingesta taken in too large quantity, 
or of a kind which is with difficulty digested. Cherries, currants, raisins 
the parenchyma of oranges and lemons, dried fruits and confectionery, 
which are so often heedlessly given to children, are common causes of acute 
attacks of indigestion. These substances, being but partially digested or 
not at all, and sometimes accumulating for days in the stomach or intes- 
tines, may lead to a very serious and dangerous condition. 

Symptoms The nursing infant, if the milk continually disagree with 

it, is fretful. It has a discontented aspect. It seldom smiles, and is not 
amused by playthings, or is only amused for a short time. Its features are 
pallid, and bear the appearance of faulty nutrition. Its body and limbs 
are more or less wasted, or are soft and flabby. Vomiting is frequently 
present, and sometimes a large mass or masses of caseum are ejected, which 
have evidently lain a considerable time in the stomach. The bowels may 
be constipated or loose, and the evacuations are unhealthy. This state of 
the infant continuing prevents. the necessary rest of the mother, and may 
affect unfavorably her health, so as to reduce the quantity of her milk, or 
render it still more unwholesome. 

In addition to the habitual indigestion, these infants sometimes have 
acute attacks, similar to the acute dyspepsia of adults, and which have 
been described by writers as gastralgia or enteralgia. Their countenance 
indicates suffering ; they utter sharp cries, their thighs are often drawn over 
the abdomen, notwithstanding attempts made to amuse them. Flatulence 
is common. Bv vomiting; or an evacuation from the bowels, the offending 
substance is removed, and the pain subsides. 

Indigestion in the spoon-fed infant is similar to that in the infant who 
nurses, except that it is ordinarily accompanied by symptoms of greater 
gravity and persistence, and there is in such infant more liability to the 
acute attacks. 

In those who have advanced beyond the age of infancy, chronic indi- 
gestion is less frequent than in infants, but as the diet of such children is 
prepared with less care, and is less restricted, they are very liable to attacks 
of temporary indigestion. These come on suddenly, and sometimes are so 
severe as to endanger life. The child, previously well, is suddenly seized 
with languor ; the pulse becomes accelerated, the face flushed, and surface 
hot. Drowsiness compels him to seek the bed, where he lies with his eyes 
shut. He sometimes has headache, and a sensation of oppression in the 
epigastrium. The nervous system is not infrequently affected, as shown 



612 INDIGESTION. 

by tenderness of a neuralgic character of the body and limbs, sudden 
twitching of the limbs premonitory of convulsions, and occasionally severe 
and repeated convulsions. These alarming and really dangerous symp- 
toms speedily subside on the removal of the cause. One of the most severe 
attacks of eclampsia which I have seen occurred in a boy eight or ten years 
old, induced by swallowing the parenchymatous portions of oranges which 
he had been in the habit of eating, and which had accumulated in the 
stomach and intestines. The expulsion of the offending substance gave 
immediate relief. 

Sometimes, but not often, the symptoms of acute indigestion closely re- 
semble those of pneumonitis. For example, an infant, whom I once treated, 
was seized at night with fever, hurried respiration, and the expiratory 
moan, which writers consider almost pathognomonic of pneumonitis or pleu- 
ritis. These symptoms subsided when the bowels were freely opened, and 
currants, which had been eaten the previous day, were expelled. 

As the child advances in years and its general health improves, the 
digestive function is^ less frequently disturbed. After the age of three 
or four years indigestion is much less frequent than in infancy and early 
childhood. 

Indigestion leads to some of the most common and serious affections of 
early life. In the infant, if it continue a considerable time, inflammation 
of the buccal, oesophageal, or gastric mucous membrane, or of some part 
of the intestinal tract, ordinarily occurs. In the young infant thrush soon 
makes its appearance, and, whatever the age, the cachexia which results 
from continued indigestion increases the liability to organic maladies. 
Eclampsia is, as we have seen, a serious, and at the same time a not 
infrequent, result of temporary or acute indigestion. 

Prognosis In simple indigestion this is good. It is doubtful or un- 
favorable when ulterior diseases occur, and in proportion to their gravity. 

Treatment The first indication in treatment is obviously the removal 

of the cause. In acute indigestion, when there is reason to believe that 
there is some offending substance in the stomach or intestines, if the symp- 
toms occur soon after the substance is taken, an emetic may be adminis- 
tered, and ipecacuanha, in syrup or powder, is safe and usually efficient. 
If several hours have elapsed a purgative should be given, as castor oil, 
either alone or in combination with syrup of rhubarb. 

If the symptoms are urgent, especially if convulsions are threatened, 
we should not wait for the slow action of a purgative, but should resort 
to enemata to open the bowels. Sometimes the pain in acute indigestion 
is such as to require the use of opiates. In the infant there is often an 
excess of acid in the stomach and intestines, which is best treated by 
alkaline remedies, as lime-water in combination with the opiate. The 
follow in 2 mixture will be found useful in such cases : — 



TREATMENT. 613 

R. Tinct. opii deodorat., or liq. opii co'mposit. (Squibbs), gtt. xij ; 
Magnes. calcinat., gr., xij ; 
Sacch. alb., 5ij i 
Aq. anisi, §iss. Misce. 
Dose, tbe bottle being first sbaken, one teaspoonful every two hours to a child 
a year old, until relief. If there is much pain, it is well to add a little chloroform 
or Hoffman's anodyne to the mixture. 

Or the following mixture : — 

R. Tinct. opii deodorat., or liq. opii composit., gtt. xij ; 
Bismuth, subcarbonat., 3iss ; 
Syr. Simplic, ^ss. Misce. 
Aq. Cinnamomi, !§j. 
Shake bottle thoroughly and give one teaspoonful. 

If in the acute indigestion of infants there is diarrhoea, the camphor- 
ated tincture of opium, in combination with chalk mixture, may be given, 
fifteen drops of the one to a teaspoonful of the other, or the above mixture. 
Infants, whose diet consists largely of cow's or goat's milk, digest with 
most difficulty the caseum, which is apt to pass the bowels in an imper- 
fectly digested state, or to collect in a large and firm mass in the stom- 
ach, causing gastralgia and rendering the child fretful .till it is vomited. 
I have elsewhere recommended, as important to prevent these attacks of 
acute dyspepsia, the use of the upper third of the milk which contains 
less than the average caseum, and the addition of an alkali to the milk, 
which retards the coagulation till it begins to be acted upon by the gastric 
juice, and tends to prevent the formation of large and firm caseous coag- 
ula in the stomach. 

In chronic indigestion the means of relief are different. They are two- 
fold : first, as regards change of diet ; secondly, measures to improve the 
digestive function. Spoon-fed infants, suffering from habitual indigestion, 
require the utmost care as regards the character of their food, its prepara- 
tion, and the times of feeding. Often it is best, if practicable, to procure 
a wet-nurse, and sometimes removal to a more salubrious locality is fol- 
lowed at once by improvement in the digestive function. If the infant is 
already wet-nursed, the milk should be examined microscopically and 
otherwise, and inquiry should be instituted in reference to the health and 
diet of the wet-nurse. Sometimes a change of wet-nurse is advisable. 
For facts and considerations bearing on this point the reader is referred 
to the chapters relating to regimen. 

Children with chronic indigestion are occasionally much benefited by 
the moderate and judicious use of alcoholic stimulants. They should be 
given sparingly with their food, and should be discontinued as soon as 
the digestive function is fully restored. M. Donne and some other French 
writers recommend the habitual use of wine for infants even in a state of 



614 INDIGESTION. 

health, but there are reasons, moral as well as physical, why alcoholic 
stimulants should only be used as medicines, and not in a state of health. 

If the case is one of simple or uncomplicated indigestion, tonics, either 
the mineral or vegetable, may be employed. In many instances, however, 
especially in infancy, gastro-intestinal inflammation has supervened, and 
in such cases those tonics should be employed which exert a favorable, or, 
at least, not an unfavorable effect on the hypereemic and irritable surface 
over which they pass. 

When indigestion is simple, or accompanied by no serious complication, 
wine of iron, citrate of quinine and iron, and the elixir of calisaya bark, 
may be mentioned among the safe and efficient agents to improve the 
digestive function. The following is also a good formula for cases of 
simple indigestion : — 

R. Ferri et animon. citrat., gr. xvj ; 

Bismuth, et arnmon. citrat., gr. xlviij ; 
Aquse, ^ij. Misce. 

Dose, tablespoonful three or four times daily to a child of two or three years. 

The ferruginous preparations are most efficacious in cases which are 
attended by signs of anaemia. 

Among the useful vegetable stomachics and tonics may be mentioned 
the compound tincture of cinchona, compound tincture of gentian, infusion 
of columbo, fluid extract of columbo, and fluid extract of cinchona. 

If chronic indigestion is complicated with gastro-intestinal inflamma- 
tion, subacute or chronic, for this is the form which is usually present, 
there are still certain tonics which may be advantageously administered. 
Columbo and the compound tincture of cinchona are often useful in these 
cases, and of the chalybeates wine of iron or the citrate of iron and am- 
monia or the liquor ferri nitratis may be safely administered. 

I have not alluded to the use of pepsin as a remedial agent in indi- 
gestion. The theory of its employment in atonic states of the stomach is 
good, but physicians in this country have, in most instances, failed to ob- 
serve that benefit from its use which they had been led to expect, and 
which seems to have followed its employment in the practice of some of 
the European physicians. Perhaps the result would have been better had 
fresher and better preparations of pepsin been prescribed. Boudault's 
pepsin from Paris has been most used in this country, but the American 
preparations are probably equally good. I have prescribed it in doses of 
two or three grains, several times daily, to foundlings from one to three 
months old, and in proportionate doses to older infants, but I am not able 
to speak confidently of its effects, as I have commonly given it with bis- 
muth. 

The American pepsin, prepared under the intelligent supervision of ex- 
perienced chemists, can be obtained in the shops in the form of a powder 
or liquid. From its freshness and unobjectionable taste it possesses ad- 
vantages. 



CONGESTION" OF THE STOMACH — GASTRITIS. 615 

Infants affected with diarrhoea from indigestion often improve under the 
use of powders consisting of equal parts of subnitrate of bismuth and 
pepsin. An infant of three months can take three grains of each every 
three hours. 

Dyspepsia often rapidly disappears by hygienic measures without the 
use of medicines, as by removal from the city to the country, outdoor 
exercise, or, if the patient is an infant, by being carried into the open air 
daily. In infants, also, marked improvement is often observed on the ap- 
proach of the cool and bracing weather of autumn and winter. 

Congestion of the Stomach. 

Passive congestion of the stomach is described among the diseases of 
this organ by Billard ; but it is a pathological state of little importance in 
itself. It occurs in new-born infants, asphyxiated at birth and with diffi- 
culty resuscitated. In these cases there is generally intense capillary con- 
gestion throughout the system. The mucous membrane of the stomach is 
injected, but not more than that of the mouth or intestines. If circulation 
and respiration are fully established, this injection of the capillaries sub- 
sides. No treatment is required, except measures to promote the circula- 
tory and respiratory functions. In cyanosis and atelectasis there is often 
general congestion of the capillaries of the systemic circulatory system, on 
account of the obstruction to the flow of blood through the heart in the one 
disease and through the lungs in the other. There is in these cases passive 
congestion of the stomach, but not more than of the other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct con- 
tact of some irritant, is rare in infancy and childhood, independently of 
disease in some other portion of the intestinal tract. Cases have, how- 
ever, been reported in which it was not known that any irritating ingesta 
had been taken, and in which a careful examination revealed a healthy or 
nearly healthy state of other portions of the digestive tube. The subjects 
were, for the most part, young infants. The following is an example re- 
lated by Billard : — 

An infant, four days old, remarkable for the color of his face and firm- 
ness of flesh, refused the breast and vomited yellow, acid matter. On the 
following day the vomiting had increased, the legs were cedematous, face 
pale and pinched, respiration difficult, skin cold, pulse slow and irregular, 
and pressure on the epigastric region produced cries indicative of pain. 

Third day : general sinking ; face thin and expressive of great pain ; 
stools natural. 



616 GASTRITIS. 

Fourth and fifth days : condition the same. Death occurred on the 
sixth day, and the autopsy was made on the day following. 

With the exception of slight pneumonitis, no disease was discovered in 
any part of the system besides the stomach. The mucous membrane of 
this organ was intensely vascular near the cardiac orifice and along the 
lesser curvature. It was also tumefied, and could be easily raised with 
the nail. In the remainder of this organ there was strongly marked capil- 
liform injection. 

This case is interesting as showing what may happen, though rarely. 
A nursing infant is seized with gastritis without apparently having taken 
any irritating ingesta, and without other disease of the digestive apparatus. 
It is probable, however, that, in cases like the above, the cause, if ascer- 
tained, would be found in the ingesta : perhaps drinks too hot, perhaps 
elements of colostrum, or pathological elements in the milk, which might 
produce gastritis in young infants in whom the mucous membrane is deli- 
cate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflammation 
of the intestines. The latter inflammation is sometimes apparently sub- 
ordinate to the former, and, if such patients die, the fatal result is due 
mainly to the gastric disease. 

Cause Gastritis, as I have observed it in infants, has been in most 

cases due in great part to the continued use of improper food, of food not 
suitable to the age of the child, and which was, therefore, with difficulty 
digested. Milk, acid, or otherwise unwholesome, farinaceous substances, 
stale or of an inferior quality, and not properly prepared, drinks too hot 
or too cold, may be specified among the causes. Therefore, this disease 
is most common in bottle-fed infants, and is comparatively rare in 
those who receive abundant and wholesome breast-milk. Anti-hygienic 
agencies, apart from the diet, no doubt exert some influence in the pro- 
duction of gastritis, as they do of stomatitis. Uncleanliness, and resi- 
dence in damp and dark apartments, or in an atmosphere loaded with 
noxious gases, produce a condition of system which strongly predisposes 
to these inflammations, if, indeed, they may not be enumerated among the 
direct causes. 

Rilliet and Barthez have called attention to the fact that certain medi- 
cinal substances given to children occasionally cause gastritis. They have 
observed this effect from the use of tartar emetic, Kermes mineral, and 
croton oil. Gastritis occurring in this way may or may not be associated 
with inflammation in contiguous portions of the digestive tube. Else- 
where I have related a case in w 7 hich gastro-enteritis occurred in a child 
nine years old, after having taken a considerable quantity of kerosene oil 
for spasmodic croup. 

Inflammation of the stomach is thought by some to accompany measles 
and scarlet fever during the eruptive period, but this opinion is probably 



SYMPTOMS. 617 

incorrect. If it occur, it corresponds with the stomatitis and dermatitis 
of those diseases, and disappears as they subside. It is mild, and accom- 
panied by few symptoms. I have, as stated in the remarks on scarlet 
fever, examined in certain instances the stomachs of those who had died 
during the eruptive period of these diseases, and found them free from any 
appreciable inflammatory lesion. 

Age From the records of about seventy cases of inflammatory disease 

of the digestive mucous membrane which I have preserved, it appears 
that gastritis is rare over the age of six months. On the other hand, it is 
not uncommon in infants under the age of three months who are deprived 
of the breast-milk. I have met it chiefly in foundlings fed with the bot- 
tle, and having at the same time entero-colitis and often also stomatitis 
and cesophagitis. In these cases there is sometimes continuous or almost 
continuous injection and thickening of the mucous membrane, from the 
lips to near the pyloric orifice of the stomach, and even beyond this orifice 
in the intestines. The following is an example of gastritis as it frequently 
occurs in foundling institutions : — 

Case R. AY., female, two weeks old, was admitted into the New York 

Infant Asylum, August 24th, I860, anaemic and somewhat emaciated. It 
was in part wet-nursed, and in part bottle-fed. The emaciation increased, 
and nearly the entire buccal cavity became covered with the confervoid 
growth of thrush. On September 4th, diarrhoea commenced. Borax was 
used for the mouth, and alkalies and astringents to check the diarrhoea, 
but without material improvement. 

The following was the record for September 7th : " Cries almost con- 
stantly, with feeble or whining voice ; still has thrush ; nurses and does 
not vomit ; stools five or six daily, and green ; pulse 136, feeble." Death 
occurred September 8th. 

Autopsy September 9th Mouth and fauces not examined ; mucous 

membrane of oesophagus vascular in its whole extent, with slight thicken- 
ing, but without ulceration ; mucous membrane of stomach injected like 
that of the oesophagus, and somewhat thickened, except in its pyloric ex- 
tremity, where the appearance was natural, or nearly so ; the color in the 
central part of the inflamed gastric membrane was deep red ; no thrush 
was noticed, except on the buccal surface during life ; along the great 
curvature of the stomach were Avhite flakes, resembling those of thrush, 
but which were found by the microscope to consist mainly of oil-globules 
and epithelial cells, without the cryptogamic formation ; mucous mem- 
brane of small intestines healthy in their whole extent, except slightly 
increased vascularity in a few places in the ileum ; mucous membrane of 
colon much injected throughout, except near the ileo-coecal valve, where 
the vascularity was slight ; in the transverse and descending colon, the 
redness was pretty uniform ; and the membrane was thickened, but not 
ulcerated ; solitary gland and Peyer's patches somewhat elevated. 

The observations of Valleix show how frequently gastritis is associated 
with severe attacks of thrush. In twenty-three of his cases of the latter 
disease, in which the condition of the stomach was noted after death, this 



618 GASTKITIS. 

organ presented inflammatory lesions in seventeen, and in three others 
appearances which may or may not have been due to inflammation. 

Symptoms A difficulty exists in isolating and defining the symptoms 

of gastritis, from the fact that it commonly coexists with other inflamma- 
tion of the digestive tube. Though we may never be able to diagnosticate 
this catarrh as certainly as we can croup or pneumonitis, still, there are 
symptoms which arise directly from the gastritis, and with care we may 
be able to distinguish them from those symptoms which are due to other 
pathological states. 

If gastritis is acute, pain is present. In the above case from Billard, 
as well as in a case observed by myself and related under the head of 
gelatinous softening, there were frequent cries, and the countenance indi- 
cated much suffering, until the stage of collapse. If there is less intensity 
of inflammation, and the disease is more protracted, as is ordinarily the 
case, the pain is not so severe, and it may be so slight as not to attract 
attention. Sometimes there is tenderness, so that pressure upon the epi- 
gastric region is badly tolerated. Vomiting is regarded as one of the 
most constant symptoms. The infant after nursing seems in distress till 
the milk is returned, but it nurses with avidity in consequence of the 
thirst, if it is not too exhausted or feeble. The dejections may be quite 
regular throughout the disease, as in the case from Billard. There is ordi- 
narily, however, diarrhoea from the presence of entero-colitis. The pulse 
is sometimes accelerated, and sometimes nearly natural. The emaciation 
in gastritis is rapid, since not only the milk is in great measure vomited, 
but the digestive function, so far as the stomach is concerned, is seriously 
impaired. The features become wrinkled and senile, the eyes hollow, the 
limbs attenuated, and the cranial bones uneven. Death occurs from ex- 
haustion. 

Anatomical Characters Simple gastritis may affect the entire 

mucous surface of the stomach, or be limited to a certain part. The part 
which is most likely to escape is that towards the pyloric orifice. This 
portion of the organ is sometimes found in nearly or quite the normal 
state, while the cardiac half or two-thirds is inflamed. The vascularity 
of the diseased surface is not uniform. In one place there is simple 
arborescence ; in another intense continuous redness, and between these 
two extremes are different grades of vascularity. The mucous membrane 
is somewhat thickened, softened, and the secretion of mucus increased. 
Extravasation of blood is not infrequent under the mucous membrane, 
usually in points, and the mucus may be mixed with more or less blood. 
Small shreds or portions of coagulated milk are often found with the 
mucus attached to the gastric surface. 1 have observed, though rarely, 
small superficial ulcers at the point where the inflammation had been most 
intense. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 619 

Diagnosis. — In protracted cases, when entero-colitis is present, it is 
difficult to make a positive diagnosis. Our opinion must then be little 
more than a plausible conjecture. In the acute attacks we can diagnosti- 
cate the gastritis with more certainty. If a young infant affected with 
thrush is seized with pain, and it vomits often ; if emaciation is rapid, and 
there is no diarrhoea, or diarrhoea not sufficient to account for the prostra- 
tion ; if the buccal mucous membrane, dotted with the points of thrush, 
presents a dry appearance and the deep-red color of severe stomatitis, 
there can be little doubt of the presence of gastritis. The diagnosis is 
rendered more certain by signs of tenderness when pressure is made upon 
the epigastric region. 

Prognosis Like other inflammations, gastritis is probably sometimes 

so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 
subsides. In other cases, by the continuance or increase of the cause, the 
inflammatory process becomes more severe and extensive, resulting even 
in disintegration of the mucous membrane. Those cases are especially 
severe and likely to end fatally, which are protracted and accompanied 
by severe thrush, with a desiccated appearance of the buccal surface, or 
with entero-colitis. Pain, vomiting, and rapid emaciation in such chil- 
dren indicate the speedy approach of death. Improvement in the stoma- 
titis or entero-colitis is a favorable indication, but these inflammations 
may improve without corresponding improvement in the gastritis. 

Treatment — All food or drinks, except those of a bland and unirri- 
tating nature, should be forbidden. If practicable, the young infant 
should take no nutriment except the mother's milk or that of a wet-nurse. 
As there is an excess of acid in inflammation of the mucous coat of the 
digestive tube, lime-water maybe advantageously given in combination 
with the breast-milk. Opium is required to relieve the pain and quiet the 
action of the stomach. The camphorated tincture of opium, in doses of 
four or five drops to a child a month old, or the syrup of poppy, tincture 
of opium, or liquor opii compositus, in proportionate doses, maybe admin- 
istered. If there is thirst, a little gum-water should be given frequently. 
If there is much emaciation and the vital powers are failing, it will be 
necessary to resort to the use of stimulants. Stimulating enemata are 
preferable to stimulants given by the mouth. Much benefit may be an- 
ticipated from local measures. Irritation should be produced upon the 
epigastrium by mustard or other means, followed by fomentations. It is 
rarely, perhaps never, proper to use leeches, if the patient be a young 
infant. Death occurs from exhaustion, and it is, therefore, important 
that the vital powers should not be reduced. If the child is weaned, the 
diet at first should be restricted to arrowroot, rice-water, barley-water, or 
similar bland substances. In advanced stages of gastritis, animal broths 
and jellies may be required. 



620 SOFTENING. 

Follicular Gastritis —Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of fol- 
licular stomatitis. It is an inflammation affecting the gastric follicles and 
ending in their ulceration. It is not a frequent disease ; it occurs in young 
infants. Billard observed fifteen cases. The symptoms in these patients 
were similar to those in simple gastritis of a severe form. The emaciation 
and prostration were rapid, and death occurred early. We can only diag- 
nosticate the gastritis without determining its follicular character. How 
many recover it is impossible to ascertain, but the disease is apt to be fatal 
on account of the intensity of the inflammation, not only of the follicles 
but of the intervening mucous membrane. The treatment is that of gas- 
tritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs during 
epidemics of diphtheria. Allusion is elsewhere made to a case treated in 
the Nursery and Child's Hospital of this city, in December, 1859. The 
patient, eighteen months old, previously had had protracted entero-colitis, 
and died exhausted after a brief attack of diphtheria. There were lesions 
referable to the entero-colitis, and the body was much emaciated. The 
diphtheritic exudation was found covering the fauces, epiglottis, glottis, to 
the rima glottidis, the entire oesophagus, and almost the entire stomach. 
The mucous surface underneath was injected ; that of the oesophagus and 
stomach especially was very vascular, softened and thickened, and the 
submucous connective tissue was infiltrated. 

The pseudo-membrane, taken from the epiglottis and examined under 
the microscope, presented an amorphous appearance: no cells were noticed 
in it, and fibrillation was not distinct ; that from the stomach was found 
to consist almost entirely of cells, the plastic corpuscles of some writers, 
the pyoid of others. The digestive process, so far as the stomach was con- 
cerned, had evidently been almost if not entirely suspended, and hence in 
part the sudden prostration. Diphtheritic gastritis probably does not occur 
without general infection of the system with the diphtheritic virus. 

Post-mortem Digestion, Softening. 

It is now many years since the attention of the profession was directed 
to disorganization of the coats of the stomach, which is sometimes observed 
at post-mortem examinations. John Hunter first ascertained that the 
gastric juice begins to have a solvent effect on the tissues of the stomach 
soon after death. Though Hunter erred, when he stated that the coats of 
the stomach are more or less digested in all or nearly all cases, it is cer- 
tain that post-mortem digestion does take place in many cadavers, so that 
a few hours after death the gastric mucous membrane is destroyed to a 
greater or less extent, and occasionally the stomach is perforated or is even 



ITS NATURE. 621 

severed from its connection with the oesophagus. I have seen several 
examples of this post-mortem perforation in infants. 

Some of the cases of supposed pathological softening of the stomach 
reported by the older observers, seem to have been such as I have described, 
namely, cadaveric. Yet there are two other kinds of softening occurring 
in children, which are strictly pathological, the one designated white, the 
other, by Cruveilhier, gelatinous. 

White softening of the gastro-intestinal mucous membrane results from 
deficient alimentation. It has been observed only in anaemic and ill-nour- 
ished children. The mucous membrane in such loses its firmness, and is 
easily separated from the subjacent tissue. This disorganization has no 
connection with any inflammatory process. It is simply a disintegration 
of the mucous membrane in consequence of the low vitality of the patient, 
whether or not there are co-operating causes. I believe that, in a large 
proportion of infants whose systems have been reduced and blood impov- 
erished for a considerable time, the gastro-intestinal mucous membrane 
will be found after death less firm and resisting than in those who have 
been habitually robust. Probably acids which collect in the primse viae, 
have much to do with this softening. 

A vague opinion exists in the minds of most physicians as to the nature 
and even appearance of the so-called gelatinous softening of the stomach, 
and the following observations will be cited in order to give a clearer idea 
of it. 

Billard has recorded two cases with his usual minuteness, and adds : 
" What inference shall be drawn from the preceding facts and considera- 
tions ? None other than that the gelatinous softening of the stomach con- 
sists in a disorganization of the mucous membrane of this viscus, caused 
by an acute or chronic phlegmasia ; that this disorganization is charac- 
terized by an accumulation of serum in the walls of this organ ; the intu- 
mescence and gelatinous consistence of the mucous membrane in a part 
usually circumscribed, situated more frequently in the greater curvature, 
and about which the membrane exhibits more or less evident traces of an 
acute or chronic phlegmasia. . . . The softening now under consideration 
must not be confounded with another kind of softening" (white) " which 
does not usually suceeed an acute phlegmasia." 

Billard believes that, while gelatinous softening results from inflamma- 
tion of the mucous membrane, its proximate cause is an afflux of serum to 
the part in which the disorganization occurs. In one of the two cases which 
he reports, he thinks that the inflammation was acute, but in the other 
chronic, and, therefore, presenting less vascularity. 

West, in speaking of gelatinous softening, says : " Softening of the 
stomach varies in degree from a slight diminution in the consistence of 
the mucous membrane, to a state of complete diffluence of all the tissues 
of the organ. . . . When the change is not far advanced, the exterior of 



622 SOFTENING. 

the stomach presents a perfectly natural appearance, but on laying it 
open a colorless or slightly brownish tenacious mucus, like the mucilage 
of quince-seeds, is found closely adhering to its interior, over a more or 
less considerable space at the great end of this organ." 

Cruveilhier says: " This softening often proceeds from the interior to- 
wards the exterior. There is at the beginning simple separation of the 
fibres by a gelatinous mucus, and in consequence the parietes are thick- 
ened and semi-transparent. ... If the transformation be complete, the 
disorganized portions are removed layer after layer, those which remain 
becoming gradually thinner. The peritoneum alone resists for some time, 
but at length it is attacked, worn, and gives way, and perforation of the 
stomach results. The parts thus transformed are colorless, transparent, 
apparently inorganic, completely deprived of vessels, and exhaling an odor 
resembling that of milk." 

Bouchut remarks : " Softening of the mucous membrane of the stomach 
in children at the breast is not a special disease which it is necessary to 
describe by itself. This alteration is always connected with other diseases, 
and is especially with disease of the large intestine, the knowledge of which 
fact has been too long neglected. It is the consequence of the acidity of 
the liquids contained in the digestive tube of young children, liquids which 
are vary acid in the disease we have above referred to." 

Dr. Carswell states that there is a pathological softening of the mucous 
membrane of the stomach, and that when it occurs the symptoms may be 
those of gastritis or enteritis. 

Rokitansky says of this form of softening : "If we consider, in addition 
to the above remarks, the uniform localization of the disease, that in none 
of its stages it presents, either at the point of the softening, or in its vicinity, 
hypersemic injection or reddening, and that we are still less able to demon- 
strate upon the inner surface of the stomach or in the tissue of its coats the 
products of inflammation, we are constrained to infer the non-inflamma- 
tory nature of the affection." 

Without extending these extracts, it is seen that eminent authorities not 
only disagree in reference to the cause of gelatinous softening of the stom- 
ach, but that they also differ in their description of its appearance. This 
diversity of opinion is most likely attributable to the fact that the two kinds 
of softening have been confounded. Rokitansky and Bouchut probably 
refer to cases of white softening, which occurs in atonic states of the tissues 
in feeble infants, and, therefore, have concluded that softening of the stom- 
ach is not inflammatory. I believe, from my observations, that the opinion 
of Billard is correct, and that true gelatinous softening is the result of 
gastric inflammation, sometimes chronic, sometimes acute. But I have seen 
appearances which led me to think that the immediate causes of the soften- 
ing continue to operate after death, so that its amount is less at the time 
of death than a few hours subsequently. 



case. 623 

The following case, which wtis watched by myself with great interest, 
from beginning to end, is an example of inflammatory softening : — 

Case G. S., male, robust, was born July 10, 1865. The mother not 

being able to suckle the infant, and the danger of artificial feeding in the 
warm months being well understood, a wet-nurse was procured. About 
the 14th of July, this wet-nurse having insufficient milk, another was pro- 
cured temporarily, who suckled the infant till July 20th, w r hen a third 
wet-nurse was engaged, whose child, healthy and thriving, was six weeks 
old. Previously to this. time the infant appeared well. It had uniformly 
nursed vigorously and seemed satisfied. 

On the 22dof July, thrush, apparently mild, was observed in the mouth, 
and a powder, supposed to be borax, and labelled such, was obtained at a 
drug store, to be used as a wash for the mouth. This powder was after- 
wards ascertained to be alum. About five grains were dissolved in as many 
teaspoonfuls of water, and the mouth of the child was swabbed occasion- 
ally with it. A piece of linen, folded so as to resemble the tip of a nursing 
bottle, was occasionally dipped into the solution, and the infant was allowed 
to suck it. The use of the alum was commenced about 6 P.M. In the 
first part of the evening the infant slept considerably, and of course did 
not nurse often, but about 8 P.M. it began to be very fretful, and it then 
nursed more frequently. It vomited once between 8 and 10 o'clock P.M. 
In order to quiet the infant, the tip soaked in the solution was often ap- 
plied to the mouth, but there was scarcely any intermission in its crying 
Through the night it vomited again once or twice, and about the middle 
of the night had one free liquid stool, w 7 hich was passed with much tenes- 
mus. The countenance of the infant was indicative of suffering, and its 
thighs were repeatedly flexed over the abdomen, as if that were the seat of 
its distress. Paregoric in two-drop doses was several times given through 
the night, and flannel soaked with hot whisky was applied to the ab- 
domen. 

July 23d. In ignorance of the cause of the child's sickness, another wet- 
nurse was obtained early in the morning, and one-sixth of a drop of liq. 
opii compos, was given every hour, with the effect of inducing a little sleep. 
The tongue was very red, desiccated, and studded with more numerous 
points of thrush than on the previous day. It now refused to nurse, ap- 
parently from soreness of the tongue. At each attempt of the nurse to in- 
duce it to take the nipple, it rubbed the mouth across the breast, crying 
either from pain or disappointment. The alum was not used in the latter 
part of the night of the 22d, but late in the morning of the 23d it was re- 
sumed, the mistake of the druggist not being discovered till midday, when 
it was estimated that about five grains had been used. Occasionally a 
little of the solution was placed in the mouth with a spoon so as to be 
swallowed, in the belief that the thrush affected the oesophagus. The in- 
fant continued to suffer much during the day, sleeping at times a few 
minutes. Its strength was evidently failing ; its respiration regular ; pulse 
about 140; its alvine discharges yellow, of natural consistence and fre- 
quency. 

Evening 23d. Surface hot; is very restless; pulse 150 to 160; tongue 
dry, intensely red, and dotted with points of thrush. Is treated with 
opiates, a little lime-water, and fomentations. 

24th. In the first part of the clay, nursed pretty well ; in the latter part, 
could be induced to draw the breast only once or twice. The symptoms 



624 SOFTENING. 

to-day were the same as yesterday, with the exception of greater emaci- 
ation and prostration ; cranial bones uneven, and features pinched. 

25th. Pulse 140 to 148; strength rapidly failing, but it cries at times 
loudly. The milk of the nurse, placed in the mouth with a spoon, is often 
held a considerable time before it is swallowed, and deglutition seems dif- 
ficult. Respiration in the first part of the day and previously, natural ; in 
the latter part of the day, accelerated ; dejections natural ; no vomiting ; 
appearance of tongue more natural than yesterday. 

26th. Died to-day in a state of collapse at 12 J P.M. The hands were 
cold several hours before death, and the milk given it was regurgitated. 

Autopsy twenty-two hours after death Much emaciation ; no rigor mor- 
tis ; cranial bones uneven ; the upper part of the pharynx injected to the 
extent of about half an inch ; but from this point to the stomach membrane 
healthy ; mucous membrane covering the cardiac two-thirds of the stomach 
disintegrated, almost diffluent, and in places detached from the subjacent 
tissue ; mucous coat of the pyloric third of the organ nearly healthy ; along 
the edge of the softened portion the mucous membrane was vascular to the 
extent of a few lines ; the muscular and serous coats of the stomach under- 
neath the softened portion were easily torn ; the mucous membrane of the 
small intestine presented in places that degree of vascularity known as 
arborescence ; there was no destruction or softening of its mucous mem- 
brane ; the colon was healthy ; the stomach was nearly empty ; the con- 
tents of the small and large intestines were natural in color and consist- 
ence ; the other viscera were healthy ; in the left, pleural cavity was about 
one ounce of transparent serum, and a less quantity in the right cavity. 

It cannot be doubted that the softening in the above case was pathologi- 
cal. The weather at the time was warm, but the infant was placed on ice, 
and a pan containing ice was kept upon the abdomen. This infant died 
evidently of gastritis, the accompanying inflammation being subordinate, 
and in fact insignificant. At first it was a question with me whether the 
alum might not have caused the gastritis, so that the case should be pro- 
perly placed in the category of deaths from swallowing corrosive sub- 
stances. In order to determine this point, I administered alum daily to 
two kittens, commencing when they were seven days old. The quantity 
given to each was ten grains daily in two doses for three consecutive days, 
and on the two following days five grains. The only uniform result noticed 
was an increased flow of saliva, which washed some of the alum from their 
mouths, and occasionally slight vomiting. There was not even any appa- 
rent inflammation of the buccal membrane from the alum. 

Post-mortem appearances as in the above case, and similar ones are re- 
corded by Valleix and others, in which gelatinous softening coexisted with 
evident lesions of gastritis, render it highly probable, if indeed they do not 
demonstrate, that the softening is a result of the inflammation at the point 
where it occurs. 

In Yalleix's twenty -four cases of what he terms fatal muguet, softening 
of the mucous membrane of the stomach was one of the most common 
lesions, and at the same time, which is the point of interest, there were 
signs which show 7 ed conclusively the presence of gastric inflammation. 



NON INFLAMMATORY DIARRHCEA. 625 

The common coexistence of the lesions of gastric inflammation, such as 
redness and thickening, with gelatinous softening of the stomach, is cer- 
tainly most reasonably explained on the supposition that the one results 
from the other. 

I am not prepared to accept nor reject the theory of Billard, that the 
immediate cause of the softening is the afflux of serum, nor that of Bou- 
cliut, that it is an excess of acid. 

In has been said that M. Baron was able to diagnosticate gelatinous 
softening. The symptoms are those of the severe forms of gastritis. The 
vomiting, great pain, restlessness, sudden and progressive emaciation, and, 
finally, collapse preceding the fatal result, are the symptoms on which the 
diagnosis is based. The treatment should be directed to the gastritis. 
(Amer. Jour, of Med. Set., January, 1841.) 



CHAPTER VII. 

DIARRHCEA. 

Diarrhoea is frequent during the whole period of infancy. The 
French writers describe several varieties according to the character of the 
evacuations, as acescent, mucous, and serous. M. Rostan even describes 
fourteen distinct kinds. But the tendency of medical science in these 
modern times is to simplify the nomenclature of diseases — to describe 
under a single name those affections which are essentially the same though 
differing somewhat in their features. Now, all the forms of diarrhoea in 
the infant may be so grouped as to reduce the number to not more than 
three or four. In this way repetition and prolixity are avoided, as well 
as an unnecessary refinement. 

Non-Inflammatory Diarrhoea. 

The most common form of diarrhoea is that enunciated in our heading, 
which writers sometimes designate by the term simple or spasmodic. But 
often a diarrhoea which is non -inflammatory at first, becomes a catarrh. 
Thus the simple diarrhoea of infancy may become an entero-colitis from 
the continued use of improper diet. 

Causes. — These are various. Conditions or agencies which have no 
appreciable effect in the adult often increase the number of evacuations in 
young children. Food which imperfectly digests, and some of which 
perhaps ferments, stimulates the intestinal follicles to excessive secretion, 
and increases the peristaltic movements by its vitiating property, thus 
40 



626 NON-INFLAMMATORY DIARRHCEA. 

causing diarrhoea. Too frequent and abundant feeding is another cause, 
especially in young infants, some of whom may vomit the surplus food and 
remain well, but others do not. Food which cannot be assimilated be- 
comes an irritant in consequence of fermentative changes, and produces 
frequent and unhealthy evacuations. The late Dr. James Jackson, of 
Boston, directed attention to this cause of diarrhoea in his Letters to a 
Young Physician. 

The mother's milk or the milk of the wet-nurse may disagree, either 
from some temporary derangement of her system, or continued ill-health, 
or from causes which are not understood. Non-inflammatory diarrhoea in 
the nursling is the immediate result, with perhaps subsequent inflamma- 
tion. The milk in these cases frequently contains the elements of colos- 
trum. 

Fright or strong mental impressions will also in some children increase 
the number of evacuations. This cause being transient, the diarrhoea 
soon subsides. 

Another cause is exposure to cold. Children who are insufficiently 
clothed in the winter season, who are taken from a heated room into a 
cool one without sufficient precaution, or who lie uncovered at night, are 
very subject to diarrhoeal attacks from the impression of cold on the 
system. 

The cause of non-inflammatory diarrhoea may exist in the child itself. 
In some children the evolution of the teeth is attended by a relaxed state 
of the bowels, which ceases when the gum is pierced. \Vorms in the 
intestines may also operate as a cause. Diarrhoea is occasionally salutary 
within certain limits, and of course it is not strictly correct to call it a 
disease when it is a means of relief. If occurring from excessive or irri- 
tating ingesta, it is obviously conservative. 

Symptoms Non-inflammatory diarrhoea may come on suddenly ; at 

other times there are precursory symptoms continuing for some days. 
Whether or not there are antecedent symptoms depends chiefly on the 
cause. If this be exposure to cold, or the use of improper aliment, it 
commonly occurs immediately. 

Among the prodromic symptoms sometimes present are restlessness, 
disturbed sleep, transient abdominal pains, nausea or vomiting, and other 
symptoms of indigestion. The stools in simple diarrhoea differ much in 
color and consistence in different cases, and perhaps at different periods in 
the same case. In infants they are apt to be green. This color, which 
is a source of anxiety to the inexperienced, and especially to the parents, 
is often produced by trivial causes. Slight indigestion will produce it, 
and so will excess of food, even when bland and unirritating. The stools 
in infantile diarrhoea often contain particles of coagulated casein, but in 
children advanced beyond the period of first dentition, they do not differ 
materially in appearance from the evacuations of the adult. They are 



ANATOMICAL CHARACTERS. 627 

usually passed easily, but if they are acid or in any way irritating, there 
may be more or less tenesmus, especially in infants. Sometimes before 
the evacuations, there is a sensation of fulness in the abdomen. In that 
form of diarrhoea which has been designated acescent, not only are the 
stools acid, but matters vomited have an acid odor, and give an acid 
reaction. 

During the quiet hours of sleep, when no food and drinks are taken, 
the diarrhoea diminishes. If the complaint is slight, there is little thirst ; 
but if the stools are frequent and thin, especially if they approach the 
serous character, the patient is thirsty. The appetite varies, the tongue 
is moist, and covered with a light fur, and there is often more or less 
meteorism, but no abdominal tenderness. 

The features in this disease are pallid. In a few days, if the evacua- 
tions continue, there is evident loss of weight and flesh. The rotundity 
of the limbs is gradually lost, and the tissues become soft and flabby. 
But in most cases, when the malady has reached this stage, its original 
character is lost, and it has become inflammatory. 

There is no constant fever in true non-inflammatory diarrhoea. Some- 
times the pulse is accelerated in the latter part of the day, but usually 
only for a short time. 

Certain epiphenomena, as Barrier terms them, occur at times in non- 
inflammatory as well as in inflammatory diarrhoea, as for example a sym- 
pathetic cough, or, which is more serious, cerebral complications. Con- 
vulsions or stupor, indicating the supervention of spurious hydrocephalus, 
may occur in either form of diarrhoea. This disease is described else- 
where. 

Anatomical Characters It is obvious from the nature of this 

malady that it is attended by little or no structural changes perceptible to 
the anatomist. In cases supposed to be non-inflammatory, which have 
ended fatally either from the diarrhoea or an intercurrent disease, the 
most marked lesions observed have been more or less tumefaction of the 
internal glands, with perhaps diminished firmness and resistance of the 
mucous membrane. Cases like the following, which have usually been 
regarded as non-inflammatory, are not infrequent, but it seems to me 
probable that in at least a certain proportion of such cases the intestinal 
follicular apparatus has passed beyond the physiological state of an exag- 
gerated functional activity, and that the disease should be designated a 
catarrh or inflammation: Inasmuch as non-inflammatory diarrhoea, if 
protracted, is very apt to become inflammatory, it is often difficult to de- 
termine whether the malady has undergone this change, even when the 
case is fatal, and post-mortem inspection is allowed. 

On the 7th of July, 1865, a foundling, one month old, died at the Infant 
Asylum. It was much emaciated, with eyes sunken and features pinched, 
at the time of its death. It was wet-nursed towards the close of its life 



628 NON-INFLAMMATORY DIAKRHCEA. 

but the nurse's milk was insufficient. It did not vomit ; did not have any- 
marked acceleration of pulse (128 per minute), and its evacuations were 
about four daily, and thin. The stomach and intestines were pale through- 
out. The solitary glands, particularly those in the colon, and the patches 
of Peyer, were tumefied so as to be visible, and somewhat raised above 
the surrounding surface. There was probably slight thickening of the 
mucous membrane, and tumefaction of the muciparous follicles, but these 
changes were not clearly ascertained. 

Niemeyer, with others, describes even the mildest forms of diarrhoea 
under the term catarrhal inflammation, and he appears to consider the 
transient effects of a purgative as an incipient catarrh. But it seems to 
me preferable, in the present state of pathological knowledge, to regard all 
those diarrhoeas which immediately abate with the removal of the cause, and 
which are attended by no marked anatomical change, as non-inflammatorv. 

Prognosis In a large proportion of cases, non-inflammatory diarrhoea 

is not dangerous. With the adoption of suitable measures to remove the 
cause, and the use of medicines to control the discharges, the patient re- 
covers. The remark already made may be repeated here, that occasionally 
diarrhoea is salutary within certain limits, as when there is a foreign sub- 
stance in the intestines, either irritating mechanically or by its chemical 
properties, and which the diarrhoea serves to remove. 

The danger arises from complications, as spurious hydrocephalus, or from 
the emaciation and exhaustion, or from its eventuating in inflammation. 

If the rotundity of the figure and firmness of the tissues are preserved, 
showing that alimentation is still sufficient, and no complication arises, the 
diarrhoea is not as a rule dangerous. In infants that over-nurse and do not 
vomit the surplus milk, the evacuations are sometimes green and frequent, 
and yet fulness of figure is preserved, and the development of the body 
proceeds as usual. On the other band, diarrhoea attended by emaciation 
or softness or flabbiness of the flesh, involves danger, and requires imme- 
diate treatment. 

Treatment — It is necessary, in order to treat diarrhoea in infancy and 
childhood successfully, to ascertain the cause, and, so far as possible, to 
remove it. It is not till the cause ceases to operate, that we can expect a 
satisfactory result from medication. The disease may be temporarily re- 
lieved by medicine, but it usually returns at once when treatment is omitted, 
unless the patient is removed from the influence of the agencies which pro- 
duce it. These remarks are especially applicable to the diarrhoea of in- 
fants. With them very generally, when affected with this complaint, there 
is some fault as regards the quantity or quality of food. Attention to this 
matter will show the need of a change of wet-nurse, or, if the infant be 
spoon-fed, a change in the character of its food or the mode of preparation 
or even in the quantity given. Sometimes by change in the diet, and 
the adoption of hygienic measures, the complaint ceases, so as to require 



TREATMENT. 629 

no medication. If medicines are needed, and the symptoms are not urgent, 
it is occasionally advantageous to commence treatment by the use of some 
of the milder purgatives in small doses. In the infant, in whom the de- 
jections are so generally acid, an alkaline laxative, or a laxative conjoined 
with an alkali, often has a good effect as preliminary treatment. Half a 
teaspoonful to one teaspoonful of castor oil, or a proportionate dose of cal- 
cined magnesia, removes any acid or irritating substance from the intes- 
tines, and is followed by a diminution in the number of stools. The im- 
provement, however, without subsequent treatment, is usually only for a 
day or two. In this city a purgative dose of castor oil is often given as a 
domestic remedy in infantile diarrhoea, the beneficial effect from it having 
popularized its use for this purpose. Trousseau usually gave Rochelle 
salts, but this medicine is too severe and dangerous for the treatment of 
infantile diarrhoea, especially in warm months. 

If there has been previous constipation, and the diarrhoea has just com- 
menced, a purgative is obviously indicated. West says : " Provided there 
be neither much pain nor much tenesmus, and the evacuations, though 
watery, are fecal, and contain little mucus and no blood, very small doses 
of the sulphate of magnesia and tincture of rhubarb have seemed to me 
more useful than any other remedy : — 

I£. Magnesias sulphatis, 5J '■> 
Tinct. rhei, 5J 5 
Syr. zingiberis, 5j ; 
Aquae carui, 5i x « Misce. 
3j ter die for children one year old ; 

and I seldom fail to observe from it a speedy diminution in the frequency 
of the action of the bowels, and a return of the natural character of the 
evacuations." 

In diarrhoea of infants, due to indigestion, and attended by acidity, the 
following prescription is sometimes useful. By improving digestion and 
correcting acidity, it has a beneficial effect on the diarrhoea. The cases 
are, however, in my experience exceptional in which this is the proper 
remedy : — 

1$.. Pulv. ipecacuanha?, gr. ss ; 
Pulv. rhei, gr. ij ; 
Sodae bicarb., gr. xij. Misce. 
Divide in chart. No. xij. One powder every four to six hours to an infant one 
year old. 

The effect of laxative medicines, employed for the purpose of correcting 
the functions of the gastro-intestinal surface, is uncertain. If there is no 
improvement from their use within two or three days, they should be 
omitted. We must rely on astringents, opiates, and, in infants, also on 
alkalies. If the symptoms are urgent, if the evacuations are frequent and 
exhausting, these agents should be employed from the first. Much harm 



630 INTESTINAL CATARRH OF INFANCY. 

is often done, and precious time lost, by prescribing laxative mixtures 
when opiates and astringents are required. I have known them to aggra- 
vate the complaint, when, by change of measures, there was immediate 
improvement. The majority of cases of non-inflammatory diarrhoea, at 
the period when the physician is called, are best treated by the use of astrin- 
gents and opiates exclusively, proper directions at the same time being 
given in reference to the diet and hygienic management. 

Iu the diarrhoea of infants the compound powder of chalk and opium 
is an excellent medicine, containing, as it does, an astringent with the 
opiate and alkali. It may be given in doses of three grains, to a child 
one year old, every three hours. I ordinarily employ it with double its 
quantity of subnitrate of bismuth, and know no better remedy for ordinary 
cases. The following is a convenient formula for administering substan- 
tially the same medicines in the liquid form : — 

]$. Tinct. opii deodorat., gtt. xvj ; 

Bismuth, subnitrat., 5ij > 

Syr. simplic, §ss ; 

Mistur. cretae, §iss. Misce. 

Give one teaspoonful from three to four hours. 

In a large majority of cases I employ this prescription or one similar to 
it, from my first visit. If the patient is not relieved by the opiate, alkali, 
and bismuth, and by proper regimen, in all probability there is inflamma- 
tion of the intestinal mucous membrane. In patients over the age of two 
or three years simple diarrhoea approaches in character that of the adult, 
and the treatment appropriate for the adult is proper in these cases, 
allowance being made for the difference of age. In infants, in whom this 
dis 'ase, if protracted, is very liable to eventuate in spurious hydrocephalus, 
alcoholic stimulants are often required at an early period, on account of 
the prostration and feeble power of endurance. 



CHAPTER VIII. 

INTESTINAL CATARRH OF INFANCY. 

It is customary with writers to treat of inflammation of the small and 
large intestines in infancy as a single disease, for the following reasons : 
First, the symptoms of colitis, at this period of life, do not ordinarily 
differ, in any marked degree, from those of enteritis. The tormina, tenes- 
mus, and abdominal tenderness, which characterize colitis in childhood 
and adult life, are ordinarily lacking, or are not appreciable by the 



INTESTINAL CATARRH OF INFANCY. 631 

observer; and the muco-sanguineous evacautions are oftener absent than 
present. On account of this absence of symptoms, Bouchut says : "Dys- 
entery is a very rare disease amongst young children. Its existence might 
even be denied, if it had not been observed at the period of some severe 
epidemics of dysentery." If Bouchut refers, by the term dysentery, to 
the ordinary phenomena of that disease, his remark is correct ; but, as 
regards the leisions, it is erroneous, for colitis is a common infantile 
malady. Billard, after analyzing eighty cases of intestinal inflammation 
in infants, says : " From this calculation, it is evidently very difficult to 
make a correct diagnosis of inflammation of the intestinal tube in sucking 
infants, yet it would seem as if the proper signs of enteritis or ileitis were 
the rapid tympanitis of the abdomen, the diarrhoea, accompanied with 
vomiting ; while in colitis, diarrhoea alone, without tympanitis, is the 
most frequent." And again : " In consequence of the impossibility Ave 
have found to exist of tracing with exactitude the series of symptoms 
proper to inflammation of the different portions of the digestive tube, we 
shall content ourselves with presenting an analytical sketch of the causes, 
symptoms, and ordinary course of inflammation of the mucous membrane 
of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign, by which 
to determine the exact seat of intestinal inflammation in the infant, is 
admitted by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is described 
as a single disease is, that enteritis and colitis in the majority of cases 
coexist. This will be seen when we come to speak of the anatomical 
characters. 

Intestinal catarrh is one of the most common and fatal of infantile 
maladies. It is the great summer epidemic of the cities, in this country. 
Unfortunately for a correct understanding of its prevalence and mortality 
in this city, and perhaps elsewhere, it is very generally in the summer 
months when obstinate, and especially when fatal, called cholera infantum, 
although, in its symptoms and nature it is very different from that disease. 
It usually has a mild beginning and is often protracted, while true cholera 
infantum begins abruptly, is characterized by violent symptoms, and rapid 
and extreme exhaustion. 

The 1500 fatal cases of so-called cholera infantum, reported every 
summer in this city, are, with now and then an exception, cases of inflam- 
mation, generally protracted. Moreover, the excess of reported cases of 
infantile marasmus, in the second half of the year, over those reported in 
the first half, should be added to the statistics of intestinal catarrh, for 
this excess, which is noticed every year in the mortuary tables of this 
city, is due mainly to the death of those wasted infants who have lingered 
with entero-colitis from the summer months. Their marasmus is simply 
a result of the protracted inflammation. 



fc)32 INTESTINAL CATAREH OF INFANCY. 

Causes Catarrh of the intestines in infancy, I have said, is most 

frequently a summer malady — at least, in the cities. Occasionally it is 
observed in the winter, and it is then, when not due to error of diet, pro- 
duced by exposure to cold. Infants who are taken from warm to cold 
rooms, or into the open air, by heedless nurses, or who sleep uncovered at 
night, are especially liable to it, whether residing in the city or country. 
In cases occurring from such exposure the inflammatory process may not 
commence suddenly. There is often a premonitory stage of simple diar- 
rhoea, the first effect of the impression of cold. 

The influence of the summer season in causing intestinal catarrh in 
young children is forcibly shown by the statistics of this city (New York), 
in which I found from the mortuary tables which I consulted a few years 
since, that during five years over 9000 young children, chiefly infants, 
perished from the diarrhoeal maladies between the first of June and last of 
October. Indeed there is no disease, except tuberculosis, so prevalent 
and fatal as infantile entero-colitis, during the period of its epidemic occur- 
rence in the summer months, and so far as I have been able to ascertain, 
the same remark is applicable to most of the other large cities of the 
Union. 

The epidemic commences about the middle of May. From this time 
there is a gradual increase in the number affected, till the months of July 
and August, when the disease attains its maximum prevalence and mor- 
tality. During the months of September and October, the number of 
seizures and of deaths gradually abates till the epidemic character is lost. 
It is thus seen that the prevalence of intestinal inflammation of infancy in 
the city bears a close relation to the degree of summer heat. That the 
high temperature of summer is not in itself sufficient to produce entero- 
colitis is, however, obvious. In elevated localities in the country there 
may be intense and long-continued heat, and yet in such places this mal- 
ady in infants is not common. It is no doubt the noxious inhalations 
from various sources with which the atmosphere is loaded, as a consequence 
of the heat, which render the disease so prevalent in certain localities in 
the summer months. The diarrhoea which affects students in the foul air 
of the dissecting room appears in some respects similar. The exact cha- 
racter of these exhalations or vapors is not fully known, but the following 
facts are clearly established by many observations. 

Infantile entero-colitis occurs most on low grounds near the seashore. 
Thus, it is common in many parts of Long Island, on Staten Island, and 
on the flats of Westchester County. Experienced and observing physi- 
cians of this city do not send infants affected in the summer months with 
entero-colitis to these localities, but to the high grounds west of the Hud- 
son, and to the hilly parts of New Jersey, where there is comparative 
immunity from the disease, and recovery is more certain and speedy. 

But the state of atmosphere which is most favorable for the develop- 



causes 633 

ment of intestinal catarrh is found only in the cities. The filthy streets 
containing more or less decaying animal and vegetable matter, the crowded 
and unclean tenement houses, the neglected privies, the slaughter-houses, 
pig-pens, bone-boiling establishments, and the like, are so many sources 
of the most deleterious effluvia, which, inspired by the infant, produce 
diarrhoea and intestinal inflammation. Those squares of the city where 
sanitary regulations are most neglected are the very ones where the mor- 
tality from this cause is largest. 

In the year 1864, the Citizens' Association of the City of New York 
effected a complete and thorough sanitary inspection of New York island, 
and it was interesting as well as painful to note the facts observed by the 
inspectors in reference to the prevalence of the so-called cholera infantum 
(chiefly entero-colitis) along the streets and in the alleys where the causes 
of insalubrity were most abundant. 

Thus, one inspector says of this disease, it "has probably consigned 
many more to the grave during the past summer than all other diseases 
in my inspection district. In every case examined, I have found it as- 
sociated with some well-marked source of insalubrity. Vegetable and 
animal decomposition has been the most prominent cause." Another 

inspector says of the same disease: "It was found between the and 

avenues, where the street, at every visit, was found in an indescriba- 
bly filthy state, in consequence of deposits of garbage and slops. This 
was particularly noticed in front of the premises where cholera infantum 
had occurred." Such was the uniform testimony of all the inspectors. 
In the tenement houses and in portions of the city occupied by the poor, 
where the sources of insalubrity are most numerous, I believe, from per- 
sonal observation, that a majority of the infants are more or less affected 
with diarrhcea, often of an inflammatory character, during the months of # 
July, August, and September. In the more salubrious localities of the 
city, there is less of this disease, but even here the liability to it is great, 
on account of the proximity of so many sources of impure air. 

But there is another and an important element in the causation of in- 
testinal inflammation in the infant. I refer to the diet. Many an infant 
that now falls a victim would escape the disease, but for some fault in the 
character of its food. Those infants in the city who are bottle-fed from 
birth rarely go through the summer without being affected with diarrhoea, 
and a majority of such, if under the age of six months when the warm 
weather commences, are saved from dangerous if not fatal inflammation 
only by removal to the pure air of the country. 

In the families of the poor the food which is given as a substitute for 
the mother's milk is very apt to disagree with the feeble digestive powers 
of the infant. The milk of cows stabled in or near the city, their food often 
being scanty and of poor quality, is unwholesome and deficient in nutritive 
properties, and this milk is in common use in the tenement houses. In- 



634 INTESTINAL CATARRH OF INFANCY. 

fants to whom this and other improper articles of diet are given are the 
first to suffer with diarrhoea as warm weather commences, and finally with 
entero-colitis. 

It is seen that the causes of intestinal inflammation of infancy as it 
prevails in the cities during the summer are mainly twofold, atmospheric 
and dietetic — an insalubrious state of the air which the infant breathes, 
and unsuitable food. Among the poor of the cities, both these causes 
conspire to produce the diarrhoeal maladies. It is easy, then, to see why 
there is so much intestinal disease and so great mortality among the infants 
of the city poor, who on account of their feeble powers of resistance and 
endurance are especially liable to be affected by and to succumb under 
morbific agencies. 

It is a common belief that dentition is one of the chief cause ?• of infantile 
diarrhoea, whether inflammatory or non-inflammatory. There is, indeed, 
great liability to this disease during the period of dental evolution. The 
following statistics, which were mostly collected during my term of ser- 
vice in one of the city dispensariss, and which comprise all the cases of 
diarrhoea under the age of about five years which were brought into that 
institution for treatment during the summer months of my attendance, 
show the preponderance of cases in the time of teething. Most of these 
diarrhoeal cases were evidently inflammatory. 

Stage of dentition. Number of cases. 

No teeth 47 

Cutting incisors ......... 106 

" anterior molars ....... 41 

" canines ......... 40 

" last molars ........ 20 

Having all the teeth 28 

» 

Total 282 

It is seen that although a large majority of the above cases occurred 
during dental evolution, yet in a certain proportion, about one in four, 
teething could not operate as a cause. My own opinion is that dentition 
is an occasional cause of simple diarrhoea, though a subordinate one, but 
that it does not of itself produce inflammation. The diarrhoea of denti- 
tion is non-inflammatory, terminating in inflammation, if such a result 
follow by the co-operation of other and distinct causes. This subject is 
treated of in our remarks relating to dentition. 

An important predisposing cause of intestinal inflammation in infants 
is the rapid development of the intestinal crypts and follicles. This de- 
velopment, which increases the liability to organic diseases of the intestines, 
is coincident with dentition. Another important cause remains to be 
notified, namely, weaning. Weaning is a subject to which less attention 
is given than its importance demands. The summer succeeding the change 



AGE. 635 

of diet is always in the city a time of great clanger to the infant from 
diarrhceal affections. Mothers uniformly speak with dread of the second 
summer. In this city, nearly every infant taken from the breast between 
the months of April and October very soon becomes affected with diar- 
rhoea which, if not inflammatory in its commencement, soon becomes such. 
Weaning in the cool months involves less danger, but even then the suc- 
ceeding summer is one of peril. I have memoranda of the time of wean- 
ing in forty-six infants who were affected with diarrhoea apparently from 
its duration and obstinacy of an inflammatory character. 

Weaned in spring or summer ...... 35 

" " autumn or winter ...... 11 

46 

The reader is referred, for other particulars in reference to weaning, to 
the chapter devoted to this subject. 

The above facts and statistics, to which more might be added, suffice to 
show the causative relation of foul atmosphere and injudicious feeding to 
the intestinal inflammation of infancy. 

This catarrh also occurs as a complication of certain diseases, especially 
the eruptive fevers. It is the opinion of some, that in measles and scarla- 
tina there is often mild catarrh of the intestinal mucous membrane, coex- 
isting with the eruption upon the skin, and disappearing with it. But in 
a proportion of cases, most frequently in measles, a more intense inflamma- 
tion arises, constituting a serious complication. The peculiar intestinal 
catarrh in typhoid fever is well known. 

Age — My observations in reference to the age at which this disease 
occurs were made in the summer months, and, therefore, relate to the sum- 
mer epidemic. The cases embraced in the following table were nearly all 
observed between the months of May and October inclusive : — 

Age. Number of cases. 

5 months, or under . . . . . . . .58 

From 5 months to 12 212 

" 12 " 18 174 

"18 " 24 93 

" 24 36 36 

Total 573 

This table shows that the infant under the age of six months is less 
liable to entero-colitis than between the ages of six months and two years. 
The small comparative number, however, affected under the age of six 
months, I attribute to the fact that most of the infants under this age 
were wet-nursed. Observations made in the institutions of this city in 
which foundlings are received show that, the younger the infant is, the 
more liable it is to be affected with this disease, under unfavorable condi- 
tions of atmosphere and diet. Thus, in the New York Infant Hospital, 



636 INTESTINAL CATARRH OF INFANCY. 

prior to the adoption of wet-nursing, a large proportion of the foundlings 
received died of well-marked entero-colitis in the first and second months, 
and veiyfew lived till the age of six months. A similar fact was observed 
in the New York Infant Asylum in Bloomingdale. 1 During my term of 
service in this institution I preserved notes of forty -nine fatal cases, which 
I diagnosticated entero-colitis, and in many of which post-mortem exami- 
nations were made. Of these cases eighteen were one month old or. under, 
fifteen from one month to three, eight from three to six, and only eight 
over the age of six months. 

Symptoms. — Intestinal catarrh in the infant is announced by the 
occurrence of lassitude, febrile movement, and perhaps fretfulness, soon 
followed by diarrhoea. The stools are thinner than in health, and their 
color is yellow, brown, or green. Infants having a milk diet are apt to 
pass green and acid stools containing particles of undigested casein. 

The tongue in the commencement of this malady is moist and covered 
with a light fur. At a more advanced stage it may be moist, but is often 
dry, and in dangerous forms of the malady is accompanied by prostration. 
The buccal surface is red, the gums more or less swollen and sometimes 
ulcerated, and sprue often appears upon the gums, tongue, and contiguous 
parts. Vomiting is a common symptom, commencing in some cases early, 
but in others not till the diarrhoea has continued a few days. Sometimes 
it appears to be a symptom of indigestion produced by the imperfectly 
digested or fermented and acid food in the stomach. Occurring at a late 
period it may have a cerebral origin from commencing spurious hydro- 
cephalus, or it may be due to impaired function of the kidneys in conse- 
quence of which urea is retained in the system, and is excreted in the 
stomach. The matter vomited, when the vomiting is due to irritating sub- 
stances in the stomach, has a sour odor, and produces a decidedly acid 
reaction w 7 ith the appropriate tests. It contains coagulated casein, and 
undigested particles of whatever food has been given. I found from ob- 
servations made in 1863 and 1864, in reference to the summer intestinal 
catarrh of infants, that vomiting commenced in less than one week after 
the diarrhoea, in a majority of the cases which I observed in those years. 

The stools sometimes continue during the whole course of the malady of 
nearly the same character as at first. In other patients they vary in color 
and consistence at different periods, this change being due partly to the 
nature of the food. In the same case they may be brown and- offensive 
at one time, green like mashed vegetables at another, and again they may 
contain masses of a putty-like appearance, the partly digested casein. 
They may consist largely of mucus, with or without blood, such stools 

1 This institution was discontinued within a year after its establishment, all 
connected with it becoming discouraged from the great mortality of the foundlings, 
who were chiefly bottle-fed. 



SYMPTOMS. 637 

indicating a predominance of inflammation in the colon. The malady, 
which BaiTier designated mucous diarrhoea, is chiefly a colitis. The 
stools are sometimes yellow when passed, but become green by exposure 
to the air, or from chemical reaction due to admixture with the urine. 

The microscopic examination of the stools in this malady is interesting ; 
I have found in them undigested casein, unaltered or slightly digested 
fibres of meat, crystalline formations, epithelial cells, single or arranged 
in clusters as if just detached from the villi, mucus, sometimes blood and 
pus cells. The stools in some infants continue, during the whole course 
of the entero-colitis, of nearly the same character as at first. In other 
cases they vary, at different periods, in color as well as consistence. They 
sometimes have a putty-like appearance, from the partly digested casein ; 
at other times they are brown and offensive. A very common appearance 
is that which has been likened to spinach or chopped vegetables ; occa- 
sionally the stools consist largely of mucus, with perhaps a little blood — 
the mucous diarrhoea of Barrier. This occurs when colitis is a principal 
part of the disease. The evacuations are seldom so watery as in true 
cholera infantum. 

Occasionally they are yellow when passed, but become green on ex- 
posure to the air, or from chemical reaction resulting from admixture of 
the urine. 

The microscopic character of the stools in entero-colitis is interesting. 
Aside from undigested casein, I have found unaltered fibres of meat, crys- 
talline formations, epithelial cells, single or arranged regularly in clusters, 
as if detached from the villi, mucus, sometimes blood, and, in one case, 
an appearance resembling three or four crypts of Lieberkuhn united. If 
the stools are green, colored masses of various sizes, but mostly small, are 
also seen with the microscope. The microscopic elements, then, are the 
excrementitious substances, particles of undigested food, inflammatory 
products, and epithelial cells or fragments of the mucous membrane, 
thrown off by the inflammatory process. 

The pulse in entero-colitis is accelerated. There is, frequently, increased 
heat of surface in the commencement, but, as the disease continues, the 
vital powers soon become reduced, and the surface is either of the natural 
temperature or cool. As death approaches, the pulse gradually becomes 
more frequent and feeble, and the extremities, sometimes for hours before 
life is extinct, have a cadaverous pallor and coldness. The skin, in in- 
testinal inflammation, is generally dry, and the urinary secretion di- 
minished. In severer forms of the disease, attended by frequent evacu- 
ations from the bowels, the infant does not pass its urine oftener than once 
or twice daily. The imperfect action of the skin and kidneys is a note- 
worthy feature of the inflammation. The advanced stages of entero- 
colitis are apt to be complicated by two cutaneous affections, namely, 
erythema between the thighs, probably produced by the acid and irritating 



638 INTESTINAL CATARRH OF INFANCY. 

character of the stools, and boils upon the forehead and scalp. The latter 
sometimes extend down to the pericranium, and leave permanent depressed 
cicatrices. The external irritation caused by the furuncular affection has 
often seemed to me conservative, as it occurs at the time when there is 
danger from passive congestion of the brain and serous effusion. When 
entero-colitis is protracted, and the patient is much reduced, remaining 
constantly in the recumbent position, except when held in the arms of the 
mother or nurse, another symptom frequently arises, namely, a dry cough, 
which continues till the close of life, if the case be fatal, and subsides 
slowly if the disease terminates favorably. The complication which gives 
rise to this symptom will be considered hereafter. As death approaches, 
the infant sometimes becomes more fretful ; it turns peevishly from play- 
things, rolls its head, or the head has an unsteady movement; and often 
the stomach becomes more irritable. The experienced physician rightly 
interprets these symptoms as the forerunner of cerebral accidents. In 
other cases there is too great prostration even for the exhibition of restless- 
ness, and the patient lies quiet. As death approaches the infant becomes 
drowsy. The limbs are cool. It refuses to nurse, or, if spoon-fed, takes 
nutriment apparently without relish. The pupils are contracted, and in- 
sensible to light. The eyes are bleared, and a puriform secretion occa- 
sionally collects between the lids. The stools are less frequent, and the 
vomiting, if previously present, ceases. Death occurs quietly. 

Sometimes, however, convulsive movements precede death, generally 
slight, as of one arm, or of the limbs or one side. Uraemia may be the 
immediate cause of death in certain cases. 

In chronic entero-colitis there is extreme emaciation for a considerable 
time before death. The skin of the extremities lies in wrinkles; the 
joints, from contrast, appear enlarged, and the fingers and toes elongated ; 
the angular projections of the bones are prominent. The hollowness or 
the cheeks and eyes causes the infant to appear much older than it really 
is. Death occurs in a state of extreme exhaustion. 

The above description applies to infantile entero-colitis, as it so fre- 
quently occurs in the cities. It is sometimes much more violent, attended 
by much greater febrile reaction, and is more speedily fatal. Especially 
is this the case when it is due to the impression of cold : such cases are 
not infrequent in the winter months, in the country as well as city. 

Instead of the mild and gradual commencement which I have described, 
infantile entero-colitis may be preceded by violent symptoms — a true 
cholera morbus in which vomiting and purging, more or less severe, precede 
the inflammation. Among my records are cases which commenced in the 
summer season from eating gooseberries, currants, cherries, and cheese : 
the choleraic symptoms produced by these indigestible substances ending 
in protracted inflammation. 



ANATOMICAL CHARACTERS. 639 

Anatomical Characters Billard says : " In eighty cases of in- 
flammation of the intestines that I examined with great care, there were 
thirty of entero-colitis, thirty-six of enteritis, and fourteen of colitis." M. 
Legendre, in twenty-eight cases of diarrhoea, found colitis alone in nine, 
and in the cases in which enteritis occurred, colitis was also present. 
Rilliet and Barthez state that in certain rare instances almost the entire 
digestive tube is affected ; that in exceptional cases the principal lesion is 
found in the small intestines, while, on the other hand, the large intestine 
is the part of the alimentary canal which is most frequently and intensely 
inflamed. Billard describes four kinds of intestinal phlegmasia : first, 
erythematic ; second, with altered secretion ; third, follicular ; fourth, 
with disorganization of tissue. In some of the best works on diseases of 
children, published subsequently to that of Billard, different forms of in- 
flammation are described, according to the presence or absence of certain 
anatomical changes, as ulceration or softening. Practically little is gained 
by such a division of the general disease, and the lesions which are made 
the basis of the division are often merely the result of severe and pro- 
tracted, simple or catarrhal, inflammation. I have records of the post- 
mortem appearances in eighty-two cases of intestinal inflammation in the 
infant. Eleven of these occurred in private or dispensary practice; about 
fifty in the Nursery and Child's Hospital, and the remainder in the 
Infant Asylum. Since preserving these records, I have witnessed a larger 
number of post-mortem examinations of infants who died of this disease 
chiefly in the institutions, and the lesions corresponded in general with those 
already observed. The question may properly be asked, Can inflammatory 
hyperemia of the intestinal mucous membrane be distinguished from 
simple congestion if there is no ulceration and no appreciable thickening 
of the intestine ? This is sometimes difficult, and it is possible that occa- 
sionally I have recorded as inflammatory what was simply a congestive 
lesion, but I do not think that I have incorporated a sufficient number of 
such cases to vitiate the statistics. In a large proportion of the autopsies 
there was manifest thickening of the intestinal mucous membrane or other 
unequivocal evidence of inflammation. The following is an analysis of the 
eighty-two cases : — 

The upper part of the small intestine, embracing the duodenum and 
jejunum, was found inflamed in twelve cases. It was free from inflam- 
mation, and of a pale color, in fifty-one cases. The ileum was inflamed 
in forty-nine cases, and the caecal portion, including the ileo-crecal valve, 
was the part in which the inflammation was uniformly most intense, and 
to which it was often confined. In sixteen cases there was no ileitis, and 
in thirteen no enteritis whatever. Therefore, the ileum was inflamed in 
all but three of the cases of enteritis, in which the records give the exact 
location of the disease. In fourteen cases there was vascularity in streaks 



640 INTESTINAL CATARRH OF INFANCY. 

or in patches, or simple arborescence in some part of the small intestines, 
the records not stating its exact location. 

In most cases the inflamed mucous membrane was perceptibly thick- 
ened. Occasionally, especially if the vascularity was slight, the thickening 
was scarcely appreciable. In one case there was so much thickening of 
the ileum next to the ileo-cecal valve that the mucous coat appeared as if 
closely studded with small warts. Ulcers of small size were found in the 
mucous membrane of the small intestines in five cases. These ulcers in 
one case were in the jejunum, in two in the ileum, and in two in both 
these divisions of the intestine. They were for the most part quite super- 
ficial, and circular or oval. 

It is seen from the above records that the portion of the small intestine 
most frequently inflamed was the ileum. The inflammation usually affected 
the ileo-cecal valve, and extended from it to a greater or less extent along 
the small intestine. In general, when inflammatory patches were found in 
different parts of the small intestine, those in the ileum nearest the ileo- 
cecal valve presented the greatest vascularity and thickening. Billard 
noticed in his cases the frequency and intensity of the inflammation in the 
terminal portion of the ileum, and the consequent thickening of the ileo- 
cecal valve, and conjectured that the vomiting so common and obstinate 
in enteritis might be due to obstruction at the ileo-ceeal orifice in conse- 
quence of this thickening. I have often seen the orifice reduced to a very 
small size from the hyperemia and thickening of the valve, but have not 
seen any accumulation above it or other evidence of obstruction. 

The inflamed mucous membrane was softened in greater or less degree 
according to the intensity of the inflammation. Sometimes the vessels of 
the submucous connective tissue were injected, and this tissue infiltrated. 
The softening of the mucous coat, and the firmness of its attachment to 
the parts underneath, varied considerably in different specimens. I was 
able, in cases in which there was softening, to detach readily the mucous 
coat with the nail or back of the scalpel, within so short a period after 
death that it was evident that the change of consistence could not have 
been cadaveric. 

The infants in whom the duodenum and jejunum presented the inflam- 
matory lesions were, with few exceptions, under the age of three months, 
and in many of these cases there was hyperemia of the gastric mucous 
membrane, and in some also stomatitis. 

In all the cases except one, namely, in eighty-one, there were lesions 
indicating inflammation of the mucous membrane of fhe colon. In 
thirty-nine, the catarrh extended over nearly or quite the whole extent of 
this portion of the intestine ; in fourteen, it was confined to the descend- 
ing portion entirely, or almost entirely ; in twenty-eight cases, the records 
state that colitis was present, but its exact location was not mentioned. 
In eighteen of the examinations, the mucous membrane of the colon was 



ANATOMICAL CHARACTERS. 641 

found ulcerated. According to the statistics, there is colitis in nearly 
every case of intestinal inflammation in infancy, and in a large proportion 
of cases also ileitis. The portion of the colon which is most frequently 
inflamed is that in and immediately above the sigmoid flexure. If the 
colitis affect other portions also, it is nevertheless in this part that we find 
the most marked inflammatory lesions. 

The solitary glands, both of the large and small intestines and Peyer's 
patches, are involved in most cases of intestinal catarrh. Even in non- 
inflammatory diarrhoea they become tumefied, so as to be distinctly visible 
and somewhat elevated. In entero-colitis, as we have already seen, they 
present different appearances, according to the degree and duration of 
the inflammation. In recent cases, and in parts of the intestine where 
the inflammatory action has been mild, there is often no perceptible change 
of these glands except slight enlargement with vascularity. This enlarge- 
ment is most apparent if the intestine is viewed by transmitted light, when 
not only the glands are seen to be swollen, but their central dark points 
are also quite distinct. If there is a higher grade of inflammation, or 
inflammation more protracted, the volume of the solitary follicles is so 
increased that they rise above the common level and present a papillary 
appearance. Peyer's patches are in a corresponding degree thickened. 

The enlargement of these glands is due to hyperplasia, namely, an 
augumentation in the number of the elementary cells. The ulceration in 
the cases which I have examined appeared to be primarily and chiefly 
follicular. While some of the solitary glands in a specimen were found 
simply tumefied, others were slightly ulcerated, and others still nearly or 
quite destroyed. The ulcers were usually from one to three lines in 
diameter, circular or oval, with edges a little raised, and red. They re- 
sembled in appearance the ulcers in follicular stomatitis. In one or two 
instances I have seen small coagula of blood in the ulcers, and I have also 
seen ulcers which have evidently been larger, having partially healed. 
The principal seat of the ulcers was in the descending colon. They were 
either found in this portion of the intestine only, or, if occurring elsewhere, 
they were here most abundant. 

Those in whom I have found ulcers have been ordinarily over the age 
of six months, which is the time when there is greatest development and 
activity of the glandular apparatus. In none of the cases observed by me 
were Peyer's patches ulcerated, though generally tumefied. 

In cases in which the caput coli was inflamed, I have sometimes found 
the mucous membrane of the appendix vermiformis also injected and 
thickened. In one case only was there a pseudo-membrane upon the in- 
flamed surface. This was in the descending colon, and it was thin like a 
film. The rectum presented no inflammatory or other lesions, or but 
slight lesions in comparison with those in the colon. Often, when there was 
almost general colitis, the rectum was found of a pale color, or but slightly 
41 



642 INTESTINAL CATARRH OF INFANCY. 

vascular. This may explain the infrequent occurrence of tenesmus in 
infantile entero-colitis. The amount of mucus secreted from the intestinal 
surface in this disease is considerably in excess of the normal quantity. It 
often forms a layer upon the mucous membrane of the intestines, and ap- 
pears in the stools, mixed with epithelial cells and sometimes with blood 
or pus. If the quantity of mucus appearing in the stools is considerable, 
this form of intestinal catarrh has sometimes been designated mucous 
diarrhoea, or mucous disease ; but there does not seem to me sufficient 
reason, either anatomical or clinical, for considering it a distinct malady. 

The mesenteric glands are ordinarily enlarged, unless in very young in- 
fants. They are frequently found as large as a large pea, or even larger, 
and of a light color, from the anaemic state of the infant. In exceptional 
instances certain of them are found to have undergone cheesy degeneration. 
The enlargement of these glands, like that of the solitary follicles and 
Peyer's patches, occurs from hyperplasia. The condition of the stomach was 
recorded in sixty-nine cases. In forty-two it was healthy ; in seventeen 
red, apparently inflamed ; in seven of a pink color ; in three it contained 
ulcers which were probably cadaveric. The usual healthy condition of the 
stomach is a noteworthy fact, taken in connection with the frequent vomit- 
ing, in intestinal catarrh. I have stated elsewhere that stomatitis is also a 
common complication in protracted and grave cases, accompanied by spongi- 
ness of the gums, which bleed if pressed or rubbed. The buccal surface in 
these cases is more vascular than natural, and, if the vital powers are 
much reduced, superficial ulceration is not infrequent, especially of the 
gums. In infants under the age of three or four months, oesophagitis is 
also a common accompaniment of entero-colitis. 

Thrush, though a frequent complication under the age of three or four 
months, is rare in older infants. Thrush, in infants over the age of eight 
or ten months, occurring in connection with intestinal inflammation, is an 
unfavorable prognostic sign, indicating a gravity of the intestinal disease 
which commonly eventuates in death. 

There exists an opinion in the profession that the liver is in fault in this 
disease, especially in that form of it which I have described as a summer 
epidemic of the cities. This opinion is, probably, less prevalent than for- 
merly, but is still held by many, and it influences the choice of thera- 
peutic agents. 

I have notes of the appearance and state of the liver in thirty-two fatal 
cases of the epidemic entero-colitis of the summer season. Nothing could 
be seen in these examinations that indicated any disturbance in the func- 
tion of this organ. The size of the liver was in some cases very different in 
those of about the same age, but probably there was no greater difference 
than usually obtains among glandular organs within the limits of health. 
The following table gives the weight of the liver in twenty cases in which 
the weight of this organ and the age of the patient are recorded : — 



ANATOMICAL CHARACTERS. 643 



Age. 






/ 


ige. 










4 weeks 


5 ounces. 


10 months 


. 


. 


6* 


ounces 


2 months 


U 


c< 


13 


" 


. 


. 


6 


" 


2 " 


H 


(C 


14 


a 


. 


. 


9 


(c 


4 " 


5 


C( 


15 


it 


. 


. 


6 


it 


5 " 


. 6* 


<< 


15 


a 


. 


. 


>k 


« 


5 " 


9 


<< 


15 


a 


. 


. 


H 


n 


7 " 


■ 4* 


<< 


16 


a 


. 


. 


6 


a 


7 " 


6 


(< 


19 


it 


. 


. 


4* 


a 


7 " 


. B* 


(< 


20 


it 


. 


. 


H 


a 


9 " 


8 


« 


23 


a 


. 


. 


15 


a 



I do not have access to tables giving the weight of the healthy liver at 
different ages, but in none of the above examinations did the size or the 
weight seem to me to be above the healthy standard, except in one, in which 
this organ was quite fatty. But in this case the degeneration and enlarge- 
ment of the liver were doubtless due to tuberculosis. 

In most of the cases the liver was examined microscopically, and the 
only fact worthy of note observed was the variable amount of fatty matter. 
Sometimes it was in excess, sometimes in moderate quantity or rather de- 
ficient, and sometimes in greater amount in one portion of the organ than 
in another. 

The prevalent belief, then, that the liver is greatly affected in the sum- 
mer epidemic of entero-colitis, receives no corroboration from the inspection 
of this organ. The only pathological state (if it be such) observed in it 
relates to the amount of oily matter, and this obviously requires no special 
treatment. 

The cutaneous affections complicating entero-colitis have already been 
alluded to. 

Frequently at post-mortem examinations of infants who have died of 
intestinal catarrh, intussusceptions are found in the small intestines. These 
probably in general occur at the moment of, or not long before, death, as 
they are small and readily reduced, but I have in a few instances found 
intussceptions which sustained the weight of two feet or more of intestine 
without being reduced, and which, from being in their interior more vascu- 
lar than the contiguous membrane either above or below, probably occurred 
some hours, possibly days, before death, but, being sufficiently pervious to 
allow the food to pass, symptoms of obstruction were absent. 

It has been said, in speaking of the symptoms, that a cough is common 
in protracted entero-colitis when the vital powers are greatly reduced, and 
the circulation is feeble. From the great emaciation and the character of 
the cough, the physician as well as friends is very apt to suspect the pres- 
ence of tubercles. But tuberculosis is quite exceptional in these cases. I 
have, as stated above, records of eighty-two post-mortem examinations of 
infants who died of entero-colitis in the summer months, and tubercles 
were found in only one case. The cough was due to solidification of the 



644 INTESTINAL CATARRH OF INFANCY. 

posterior and dependent portion of one or both lungs. The exact patho- 
logical character of this solidification of lung (hypostatic pneumonitis) is 
treated of in our remarks on disease of the respiratory organs. 

In the cases of entero-colitis which were complicated with this state of 
the lungs, I have not usually found enough of the lung-tissue involved to 
make any perceptible difference in the sound on percussion. Its extent of 
solidification was sometimes not. more than two or three lines, and fre- 
quently not more than a quarter to half an inch in an anteroposterior 
direction, although it embraced nearly or quite the entire posterior surface 
of the organ. 

The state of the brain in the entero-colitis of infancy is interesting to 
the pathologist. When the disease is protracted, this organ wastes like 
the body and limbs. In the young infant, in whom the cranial bones are 
still ununited, the occipital and sometimes the frontal become depressed in 
proportion to the loss of brain-substance, so that the cranium is quite 
uneven. In older children with the cranial bones consolidated, serous 
effusion occurs according to the degree of waste, thus preserving the size 
of the encephalon. The effusion is chiefly external to the brain, extend- 
ing on each side over the convolutions from the base to the vertex. The 
quantity of serum varies from one to two drachms to an ounce, or even 
more. The serous effusion is associated with passive congestion of the 
cerebral vessels and cranial sinuses, and this pathological state when suffi- 
cient to produce symptoms, is the common form of spurious hydro- 
cephalus. 

The following is a common example : — 

In December, 1877, my attention was called to an infant, aged seven 
months, just admitted into the New York Foundling Asylum, with suspected 
brain disease. Its previous history had not been ascertained ; its pupils 
reacted feebly by light, and its head constantly rotated from side to side. 
The diagnosis was easy from the symptoms, for its wasted state, and 
sunken eyes, without any marked pulmonary symptoms, indicated pro- 
tracted intestinal catarrh, and the depressed anterior fontanelle, showed 
that the brain disease could not be an inflammation either meningeal or 
cerebral. It was obvious that the anatomical state of the brain, which we 
are now considering, was present. At the autopsy on the following day, 
the lesions of severe protracted intestinal catarrh were found. The large 
intestine especially, was thickened, and its mucous surface rough and un- 
even from proliferation of the mucous membrane, or sub-mucosa, which 
had evidently been going on for a considerable time. The portions of the 
surface which were roughened by this proliferation presented a dusky-red 
color. On opening the cranial cavity about one ounce of serum escaped, 
which had been effused between the superior surface of the brain and the 
meninges. The anterior portion of the brain, which was uppermost in the 
position in which the child had been in the crib, appeared normal, but the 
veins and capillaries in the posterior or depending portion were engorged 
with dark blood. The base of the brain did not present any inflammatory 
lesion. The cranial sinuses were also distended with dark blood and clots ; 



DIAGNOSIS — PROGNOSIS — TREATMENT. 645 

a long white clot was drawn out from the longitudinal sinus, being, from 
its color and firmness, in all probability, ante-mortem ; the presence of 
which, whatever the condition otherwise, obviously rendered recovery im- 
possible. 

Diagnosis Persistent diarrhoea, with elevation of temperature, indi- 
cates intestinal catarrh. Abdominal tenderness, which is so important a 
diagnostic symptom in the adult, is generally absent in the infant, or, if 
present, is not easily ascertained. It is more difficult to determine, from 
the symptoms, what part of the intestinal tract is chiefly involved in the 
catarrh, though it may be assumed that it is the colon, and the lower part 
of the ilium if the patient is under the age of eighteen months. The pre- 
sence of mucus, or of mucus tinged with blood in the stools, shows predomi- 
nance of colitis. 

Prognosis Though intestinal inflammation is one of the most fatal 

infantile maladies, still, by proper hygienic measures and a judicious selec- 
tion and use of medicines, a large proportion of those affected may be 
saved. This inflammation and most of its complications are of such a 
nature that we may have reasonable hope that the infant will, recover if 
suitable measures are employed sufficiently early. Many do recover from 
a state of emaciation and feebleness which, occurring in any other patho- 
logical state, would be almost necessarily fatal. The most unfavorable 
symptoms in this disease, except those due to extreme prostration or col- 
lapse, arise from the state of the brain. Rolling the head, squinting, 
feeble action of the pupils, spasmodic or irregular movements of the limbs, 
indicate the near approach of death. There are many facts which should 
be taken into consideration in making a prognosis. The age of the infant, 
the time in the year, the surroundings, especially in reference to the im- 
purity of the atmosphere, are to be considered, as well as the present state 
of the patient. 

Intestinal inflammation of infancy might, in many instances, be pre- 
vented by judicious measures. Especially is it preventable in those cases 
in which the exciting cause is dietetic. The reader is referred to the 
chapters on weaning and artificial feeding, for facts in reference to this 
matter. Unfortunately, however, often the physician is not consulted in 
regard to the alimentation of the infant, or the time and manner of wean- 
ing, or other important matters of regimen, until diarrhoea, inflammatory 
or non-inflammatory, is established; his purpose is then not to prevent, 
but to cure. 

Treatment. Regimenal Measures — The infant with intestinal catarrh 
is thirsty, and is, therefore, apt to take more nutriment, in the liquid 
form than it requires. If nursing it craves the breast, or if weaned craves 
the bottle at short intervals, but no more nutriment should be allowed 
than is required for the sustenance of the patient, since an amount of food 
which cannot be fully digested, undergoes fermentative changes and be- 



646 INTESTINAL CATARRH OF INFANCY. 

comes an irritant to the intestines. The infant should, therefore, take its 
food in proper quantity and at proper intervals, and if if is thirsty, it 
should take a little gum water or light barley water in the intervals. But 
exhaustion should be guarded against, and while the diet should be bland 
and unirritating, it should be nutritious. 

As one of the chief causes of intestinal catarrh, when not produced by 
exposure to cold, is the use of indigestible and therefore irritating food, it 
is obviously of the utmost importance that the food should be of suitable 
nature, properly prepared, and given in proper quantity. This remark is 
especially applicable to the catarrh of the summer months, the cause of 
which is largely dietetic. To infants under the age of one year, and par- 
ticularly under six months, no food is so suitable as the breast-milk, and 
one affected with the " summer complaint," and remaining in the city, 
will not in general do well unless it obtain the milk either of its mother 
or a wet-nurse. Many are the instances every summer, in New York 
city, in which the diarrhoea continues in spite of all other measures, 
hygienic and medicinal, till a wet-nurse is employed, when in consequence 
of the changed diet there is rapid and complete restoration to health from 
a state of emaciation and weakness. 

In certain cases the breast-milk, either of the mother or wet-nurse, dis- 
agrees with the infant, and its use aggravates the intestinal disease. In 
the country, or in the cool months in the city, weaning may be proper 
under such circumstances. Certainly weaning or the employment of* 
another wet-nurse is required. In the city in the summer months, for 
reasons elsewhere fully stated, weaning is a very injudicious if not fatal 
measure, and, if the entero-colitis is aggravated by the character of the 
mother's milk, a wet-nurse should be engaged. If the breast-milk is 
suspected as the cause or one cause of the infant's sickness, it should be 
examined by the microscope, before a change in diet or in nursing is 
recommended. It has been ascertained by the microscope, that the ele- 
ments of colostrum which have a purgative effect may return at any period 
of lactation. 

If the mother's milk disagree, and a wet-nurse for any reason is not 
employed, it is then necessary to recommend a diet which will be the best 
possible substitute for the natural aliment. For young infants the upper 
third of fresh cow's milk, which has been allowed to stand two hours, 
should be employed. For an infant of two months the milk should be 
given with one-fourth its bulk of water added, but for one over the age of 
three or four months it need not be diluted. 

It is often advisable, especially in hot weather when the lactic acid fer- 
mentation begins early, to add a little lime-water or bicarbonate of potash 
to the milk. As a rule, I think infants with intestinal catarrh, artificially 
fed, do better if a certain proportion of farinaceous food is added to the 
milk, though it may be omitted certain times in the feeding. Of the fari- 



TREATMENT. 647 

naceous articles found in the shops, I prefer Liebig's, especially Horlick's 
preparation of it, for infants under the age of five months, since in this food 
the starch is converted into glucose and dextrine. For infants over the 
age of five months, barley flour boiled half an hour, wheat flour boiled dry 
in a bag for twelve hours, Ridge's food, etc., are useful dietetic articles. 
The juice expressed by a lemon-squeezer from beef steak, rare-done, and 
given at intervals in small quantity, is also useful in most cases of intestinal 
catarrh, and particularly so when the child begins to emaciate and the 
strength fails. For facts relating to artificial feeding the reader is referred 
to the appropriate chapter. 

But one chief cause of the great summer epidemic of intestinal catarrh 
in the cities, we have seen to be atmospheric. This requires attention on 
the part of the practitioner, to a different matter in the hygienic manage- 
ment of these cases, namely, the state of the air which the infant breathes. 
In cool months the atmosphere is more pure than in the summer months, 
as it contains less of those noxious gases which arise from decaying animal 
and vegetable substances. In those months, then, in which the weather is 
such that there is no decomposition of organic matter, the atmospheric 
cause of entero-colitis is less operative, and less is gained for the patient by 
change of locality. But in the summer season one of the most important 
conditions of successful treatment of this and the other diarrhoeal maladies 
of infancy is the removal of patients from an impure to a pure atmosphere. 
Physicians of experience all agree in the choice of salubrious localities, 
containing a sparse population. Many are the instances every summer in 
this city of infants removed to the country with intestinal inflammation, 
with features haggard and shrunken, with limbs shrivelled, and skin lying 
in folds, too weak to raise or at least hold their heads from the pillow, 
vomiting nearly all the nutriment taken, with stools frequent and thin, 
resulting in great measure from molecular disintegration of the tissues, pre- 
senting indeed an appearance seldom seen in any other disease except in 
the last stages of phthisis, and returning in late autumn, with the cheerful- 
ness, vigor, and rotundity of health. The localities usually preferred by 
the physicians of this city are the elevated portions of New Jersey and 
Eastern Pennsylvania, the Highlands of the Hudson, the central and the 
northern parts of New York State, and Northern New England. Taken 
to a salubrious locality, the infant will soon begin to improve after it has 
recovered from the fatigue of travelling, unless the case is exceptionally 
obstinate. 

Sometimes parents, not noticing the immediate improvement which they 
had been led to expect, return to the city without giving the country fair 
trial, and the life of the infant is almost necessarily sacrificed. Returned 
to the foul air of the city while the weather is still warm, it sinks rapidly 
from an aggravation of the malady. Dr. James Jackson recommends, if 
the infant do not improve where it is taken, that it should be conveyed to 



648 INTESTINAL CATARRH OF INFANCY. 

another locality. This is good advice, provided that the selection be made 
of a place elevated, and having a sparse population. The infant, although 
it has recovered, should not be brought back while the weather is still 
warm. One attack of the disease does not diminish but increases the 
liability to a second seizure. 

If the situation of the family is such that it is not practicable to take 
the infant to the country, and such cases are frequent among the poor, it 
should be kept much of the time in the open air ; it is a common practice 
in this city to take such patients in the daytime to the seashore, or upon 
ferry-boats. Dr. E. H. Parker says : " Many of my patients are sent to 
the ferries to cross them, so that the cool, fresh, sea-breeze may fan them, 
and it acts sometimes like magic, to raise their drooping heads." I have 
not observed such marked benefit in these cases from the sea-breeze as 
from the air of elevated rural localities, which can generally be found in 
the vicinity of cities, and are easily accessible. 

Medicinal Treatment Sometimes it is proper to commence treatment 

by the employment of a gentle purgative, particularly when the disease 
commences abruptly from a state of previous good health. It is then 
frequently caused by exposure to cold, or more rarely by some indigestible 
and highly irritating substance in the intestines. In such patients there 
is often a full habit. The pulse is strong and quick, the heat of surface 
great, the face perhaps flushed, the stools sometimes slimy and bloody, 
sometimes green or brown. It is proper and often serviceable, when there 
is this commencement of the affection, to give a single dose of castor oil 
or syrup of rhubarb. Any indigestible substance, if present, is removed 
from the intestine, and opiates or other remedies designed to control the 
disease may then be more successfully employed. Such cases occur in the 
winter not less than in the summer, and in all localities, rural as well as 
in the city. But the summer epidemics of intestinal inflammation in the 
cities do not in general • require such preliminary treatment. Diarrhoea, 
moderate, perhaps, has already continued for a time when the physician 
is called, and no irritating substance remains except the acid, which is 
abundantly generated in the intestine in this disease, and which we have 
the means of removing without purgation. Preliminary treatment having 
been employed or not, according to the nature of the attack and condition 
of the patient, remedies calculated to arrest the inflammation should then 
be prescribed. 

The same general plan of medicinal treatment holds good for the intes- 
tinal catarrh of infants, which has been found efficacious for that of adults. 
But the causes of this catarrh are, as we have seen, in some respects dif- 
ferent in infancy from those operative in other periods of life, so as to re- 
quire some variation in the treatment. The acid fermentation occurring 
in the stomach, which is very common, especially in the catarrh of the 
summer season, requires the use of. antacids. If by the appearance of the 
stools, or the substance ejected from the stomach, or by the usual test with 



TREATMENT. 649 

litmus paper, the presence of acid in an irritating quantity be ascertained 
or suspected, lime water or a little bicarbonate of soda should be added to 
the food. The creta preparata of the pharmacopoeia, or, which is more 
convenient, the mistura cretae, administered every two hours, is an useful 
antacid for this condition. By the alkali alone, aided by the judicious 
use of stimulants, the disease is sometimes arrested; but, unless circum- 
stances are favorable, and the case is mild, other medicines are required. 
The physician should see that the chalk is finely triturated. 

Opium is used by most practitioners in the treatment of this malady. 
Either as a main remedy or adjuvant it is employed, and properly, in 
nearly all severe cases. For a young infant paregoric is an eligible prep- 
aration of opium. For the age of one month, the dose is three to five 
drops ; for the age of six months, ten to twelve drops, repeated in three 
hours or a longer time, according to the state of the patient. After the 
age of six months the stronger preparations of opium are more frequently 
used. At the age of one year the liq. opii compositus or tinctura opii 
deodorat. may be given in doses of one drop. Dover's powder is also a 
useful medicine in this disease, given in doses of three-fourths of a grain to 
an infant one year old. 

Opium is, however, in general best given in mixtures which will be 
mentioned hereafter. It quiets the action of the bowels, and diminishes 
the number of evacuations. It is contraindicated or should be used with 
caution if cerebral symptoms are present. Sometimes in the commence- 
ment of the disease, if there is much febrile reaction, the patient may be 
drowsy and in danger of convulsions. Then opiates should be given cau- 
tiously. Also in the advanced stages of this disease, when, perhaps, 
there is more or less serous effusion in the cranial cavity, opium should be 
cautiously prescribed, as it might tend to produce that fatal stupor, in 
which unfavorable cases are apt to terminate. 

Astringents have long been used as an adjuvant to the opiate, but the 
medicine, which, employed in combination with opium, is the most effi- 
cient in controlling infantile entero-colitis, is the subnitrate of bismuth. 
While it aids strongly in checking the diarrhoea, it is an efficient anti- 
emetic and antiseptic. It should be prescribed in doses of ten or twelve 
grains for an infant of twelve months, and larger doses produce no ill effect, 
for its action seems to be almost entirely local and soothing upon the intes- 
tinal surface. It undergoes a chemical change in the stomach, becoming 
black, being probably converted into the bismuth sulphide, and it produces 
dark stools. An intelligent physician has informed me that he has some- 
times observed a peculiar faint odor, somewhat like that of garlic in the 
breath of those who are taking the bismuth in frequent large doses, which 
seems to indicate that there is some absorption of it. 1 In those cases in 

1 The same offensiveness of the breath has since been noticed in two cases in my 
practice. 



650 INTESTINAL CATARRH OF INFANCY. 

which the symptoms are chiefly due to the colitis, and the stools contain 
blood with a large proportion of mucus, it has been customary to prescribe 
laudanum or other form of opium with castor oil. I now prefer, however, 
the bismuth and opium in the treatment of cases which are more decidedly 
dysenteric, as well as for cases of the usual form of intestinal catarrh. 

The following formulas are employed with the best results in the insti- 
tutions of New York, with which I have an official connection, the dose 
being for an infant of one year : — 

R. Tine, opii deodorat., gtt. xvj ; 
Bismuth, subnitrat., 5ij 5 
Syr. simplic, ^ss ; 
Mistur. cretse, §iss. Misce. 
Shake bottle. Give one teaspoonful every two to four hours. 

R. Tine, opii deodorat., gtt. xvj ; 
Bismuth, subnitrat., 5*j '■> 
Syr. simplic., §ss ; 
Syr. cinnamomi, giss. 
Shake bottle. Give one teaspoonful from two to four hours. 

R. Bismuth, subnitrat., 5U ', 

Pulv. cret. comp. c. opio, 5 3S - Misce. 
Divid. in chart. No. x. Dose, one powder every three hours. 

R. Bismuth, subnitrat., 3ij 5 

Pulv. ipecac, comp., gr. ix. Misce. 
Divid. in chart. No. xii. Dose, one powder every three hours. 

An infant of six months can take half the dose, and one of three or four 
months one-fourth or one-third the dose of either of the above mixtures. 

Enemata. — These are of great service in many cases of intestinal inflam- 
mation. At any stage of the disease, when the stomach is irritable and 
medicines are not retained, they may be advantageously employed. Lau- 
danum especially is often given in this way to the infant with great benefit. 
It may be prescribed mixed with a little starch-water, and the best instru- 
ment for administering it is a small glass or gutter-percha syringe, the 
nurse retaining the enema for a time by means of a compress. Beck, in 
his Infant Therapeutics, advises to give by injection twice as much of the 
opiate as would be administered by the mouth. A somewhat larger pro- 
portion may, however, be safely employed. 

The following formula for a clyster has given more satisfaction in my 
practice than any other which I have employed : — 

R. Argent, nitrat., gr. j : 

Bismuth, subnitrat., §ss ; 
Mucil. acacise, 
Aquae, aa §ij. Misce. 
One-quarter to one-half of this should be used at a time, with the addition of as 
much laudanum as is thought proper, and it should be retained by a compress, 
held by the nurse. 



TREATMENT. 651 

In most of those cases of intestinal catarrh which occur under the de- 
pressing effect of warm weather, alcoholic stimulants are required almost 
from the commencement of the disease, and their use is beneficial in 
chronic or protracted cases, whatever the cause or season. Bourbon 
whiskey or brandy is the best of these stimulants, and it should be given 
in small doses, repeated at intervals of two hours. I have usually ordered 
three or four drops to an infant one month old, and an additional drop or 
two drops for each month. The stimulant is not only useful in sustaining 
the vital powers, but it also aids in relieving the irritability of stomach. 

In certain cases vomiting is a prominent symptom. It is common and 
often obstinate in cases occurring during the summer epidemic, and it 
increases greatly the prostration. Sometimes it is probably due to excess 
of acid in the stomach, sometimes it is the result of the general irritability 
and increased movement of the gastro-intestinal canal, and sometimes it 
probably has a cerebral origin. The following are formulae which will be 
found useful for this symptom : — 

R. Bismuth, subnitrat., 5ij ! 
Spts. amnion, aromat., 5 SS > 
Syr. simplic, 
Aquse, aa §j. Misce. 
Shake bottle. Dose, one teaspoonful hourly, or every second hour if required. 

R. Acid, carbolic, gtt. ij ; 
Aq. calcis, :fij. Misce. 
Dose, one teaspoonful with a teaspoonful of milk (breast-milk if the baby nurses), 
to be repeated according to the nausea. 

Lime-water alone often removes the nausea when there is an excess of 
acids in the stomach, but it is rendered more effectual in certain cases 
by the addition of carbolic acid, which tends to check any fermentative 
process. 

Another remedy is the neutral mixture, prepared by the following for- 
mula, the bottle being tightly corked immediately on mixing the ingre- 
dients, so as to retain the carbonic acid : — 

R. Potass, bicarbonate, gr. xxv ; 
Acid, citric, gr. xvij ; 
Aq. amygdal. amarse, §j ; 
Aquae, §ij. Misce. 
Dose, one teaspoonful to a child from eight to ten months, according to the 
nausea. 

Dr. Sweezey, one of the attending physicians in the class of children's 
diseases at the Outdoor Department at Bellevue, and who has called my 
attention to the good effects of minute doses of ipecacuanha to relieve 
nausea in this disease, employed the following formula : — 

R. Tinct. ipecacuanha?, gtt. iv ; 
Aquse, §iv. Misce. 
Dose, one teaspoonful, repeated according to the nausea. 



652 INTESTINAL CATARRH OF INFANCY. 

I have employed all these prescriptions, and in certain cases with a 
satisfactory result, but my preference is for the bismuth in large doses, as 
it seems to afford relief in the largest proportion of cases. Nevertheless 
there are instances, especially during the summer epidemics, when this 
symptom is very obstinate, and all these remedies may fail. In these 
cases perfect quiet of the child, the administration of but little nutriment 
at a time, mustard over the epigastrium, and the use of an occasional 
small piece of ice may relieve the nausea. 

When the catarrh is chronic, and the vital powers begin to fail, as indi- 
cated by pallor, more or less emaciation, and loss of strength, the follow- 
ing is the best tonic mixture with which I am acquainted. It aids in 
restraining the diarrhoea, while it increases the appetite and strength. It 
should not be prescribed until the inflammation has assumed a subacute 
or chronic character. 

R. Tinct. colombse, ^iij ; 

Liq. ferri nitratis, gtt. xxvij ; 
Syr. simplic, §iij. Misce. 
Dose, one teaspoonful every four hours to an infant of one year. 

In the Outdoor Department at Belle vue we commonly give this tonic 
alternately with the bismuth powders. 

External Treatment Some writers recommend depletion by leeching 

in intestinal inflammation, advice likely to do harm, unless the particular 
cases are described in which it may possibly be of service. It can be 
useful only in those cases in which the infant is robust and of full habit, 
and the disease commences suddenly with decided febrile reaction. Such 
cases are oftenest seen with us in the winter season, and even these are 
ordinarily best treated without loss of blood. Sinapisms and poultices 
usually are sufficient as local measures. In these cases, also, the warm 
mustard foot-bath should be employed, and repeated if there is restlessness 
or cerebral symptoms. 

In all forms of intestinal inflammation in infancy and in all its stages, 
mild counter-irritation over the abdomen is often useful, but vesication, by 
increasing the restlessness of the infant and reducing its strength, without 
materially modifying the severity or duration of the disease, does more 
harm than good. It is not to be thought of as a remedial measure. I 
have known a troublesome sore continuing till death, and probably hasten- 
ing this result, to occur from this treatment. Poultices or fomentations 
over the abdomen are sometimes beneficial, especially those of a mildly 
irritating nature. A poultice of powdered cloves, cinnamon, and ginger, 
or of linseed meal to which a little mustard is added, may be employed, 
or a linseed poultice spread thin, under which a single layer of muslin is 
placed, saturated with camphorated oil or tincture of camphor, and over 
both oil silk. In the entero-colitis of infants, occurring in the cool 



ENTERITIS AND COLITIS IN CHILDHOOD. 653 

months, and due to exposure to cold, this treatment is especially useful. 
In the epidemic entero-colitis of the summer months, which may be aggra- 
vated by heat, treatment by poultices may be injudicious, but in such cases 
it is proper to produce moderate redness over the abdomen by temporary 
applications. 



CHAPTER IX. 

ENTERITIS AND COLITIS IN CHILDHOOD. 

Intestinal inflammation in childhood differs materially from the form 
or type which it commonly presents in infancy. Its causes, symptoms 
and extent differ in important particulars in the two periods. In child- 
hood there is not ordinarily such extensive inflammation of the mucous 
membrane of the intestines as we have seen is present in the majority of 
cases in infancy, and it may, therefore, be properly treated as two dis- 
eases, according to the seat of the morbid process, namely, enteritis and 
colitis. Both these affections in the child resemble so closely the form 
which they exhibit in adult life, that no extended description is needed in 
this connection. 

Causes A main cause is sudden reduction of temperature by exposure 

to cold, or to currents of air, which checks perspiration, and causes 
determination of blood from the surface to the viscera. These inflamma- 
tions are also caused sometimes by irritating substances in the intestines. 
I have known fecal accumulations as well as worms to produce severe 
dysentery in the child, accompanied by the characteristic tenesmus and 
muco-sanguineous stools, and ceasing as soon as the offending substances 
were expelled. The use of unripe or stale vegetables, if there js a strong 
predisposition to mucous inflammation, may be a sufficient cause, and some 
of the mcst dangerous cases are due to the accumulation in the intestines 
of seeds and the parenchyma of fruits. But the most common cause is 
that mentioned, namely, sudden exposure to cold when the body is heated, 
a danger to which children are especially liable, on account of the easy 
disturbance of the circulatory system in them, and their heedless exposure 
of themselves, unless incessantly watched. 

Enteritis and colitis are also frequently secondary diseases. They occur 
in children as complications or sequelse of the eruptive fevers, especially 
measles. 

Symptoms The alvine discharges in enteritis and colitis in childhood 

are such as occur in these diseases at a more advanced age. In enteritis 
they are thin and of the natural color, or occasionally green ; in colitis 



654 ENTERITIS AND COLITIS IN CHILDHOOD. 

they are more consistent than in enteritis, and are largely muco-sanguineous. 
Sometimes in enteritis, if the inflammation is not intense, the diarrhoea is 
slow in appearing, or it may be slight, so as not to attract special attention. 
The disease may then resemble remittent fever, for which it is at times 
mistaken. The upper part of the small intestines is less frequently affected 
than the lower. If there is duodenitis, the flow of bile is occasionally im- 
peded from tumefaction at the mouth of the common bile-duct, and the 
icteric hue appears. In both enteritis and colitis there is abdominal 
tenderness, with more or less constant pain if the disease is severe, and in 
colitis, tormina and tenesmus. The pulse is accelerated, the heat of sur- 
face augumented, the face flushed, and, except in mild cases, indicative of 
suffering. In many children at the commencement of the inflammation 
the nervous system is profoundly affected, as indicated by headache, stupor, 
twitching of the limbs, and sometimes by convulsions. The chief danger 
at the commencement of the disease is, indeed, from this source. Some- 
times there is irritability of the stomach, and the food is rejected, though 
much less frequently than in the intestinal inflammation of infancy. 
Anorexia and thirst are common symptoms. If the inflammation con- 
tinue, there is soon perceptible emaciation, with loss of strength. The 
eyes become hollow, the face pale, and the surface cool. Death may occur 
at an early period, the vital powers succumbing from the intensity of the 
inflammation. In other cases, the acute disease ends in a subacute or 
chronic inflammation ; the patient becomes gradually more reduced, till 
he dies in a state of extreme emaciation, such as we often observe in the 
entero-colitis of infancy, or from this state he may recover by degrees, 
though perhaps with an irritable state of the bowels, which continues for 
months. In a majority of cases, however, enteritis and colitis in child- 
hood, if not neglected, soon begin to yield, and they terminate favorably in 
one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the in- 
flammation. This is indicated by the fever, abdominal tenderness, and 
the relaxed state of the bowels. Whether the disease is enteritis or colitis 
is determined by the character of the stools, the seat of the tenderness, and 
the presence or absence of tenesmus. 

Prognosis It has been stated above that enteritis and colitis in child- 
ren commonly terminate favorably. The result depends not only on the 
extent and severity of the inflammation, but the constitution and previous 
health. The inflammation is more serious when secondary than when 
primary. Extensive and great tenderness of the abdomen, features pale, 
anxious, and indicative of suffering, pulse frequent and feeble, should ex- 
cite the most serious apprehensions. Frequent vomiting also denotes a 
grave form of the disease. Stupor, and especially convulsive movements, 
show that the nervous centres are affected, and should make us guarded in 
the prognosis. Improvement in the disease, on which to base a favorable 



TREATMENT. 655 

prognosis, is apparent in the diminution of the tenderness, improvement in 
the pulse and character of the stools, a more cheerful countenance, and less 
disrelish of food. 

Treatment This should be similar to that employed for the adult. 

In enteritis at the commencement of the disease, if there is reason to sus- 
pect the presence of any irritating substance in the intestines, and ordi- 
narily in colitis, it is advisable to commence treatment by the use of some 
simple evacuant, like castor oil. After this our reliance, so far as internal 
treatment is concerned, must be mainly on opiate and antiphlogistic 
medicines. One of the best remedies of this class is the Dover's powder, 
which may be given to a child five years old in doses of three grains every 
three hours. A corresponding dose of any of the other opiates may be 
given, but with less sudorific effect. In colitis the occasional administra- 
tion of a laxative should not be neglected, if the stools are entirely or 
mainly muco-sanguineous. It should be employed so as to prevent ac- 
cumulation of fecal matters in the colon, which would serve as an irritant 
and increase the inflammation. The dose should be small, merely suffi- 
cient to produce a fecal evacuation, and repeated as required, daily or 
less frequently. The laxative commonly preferred is magnesia, rhubarb, 
or castor oil. The physician may prescribe an opiate mixture containing 
sufficient of the laxative to have the effect desired, though ordinarily it is 
better to prescribe the two separately, so that the laxative can be given 
or withheld, according to circumstances, while the opiate is continued 
more regularly. Except that there is some irritating substance which re- 
quires removal, the effect of laxatives is injurious, instead of beneficial. 
Most of the formula? given above in our remarks relating to the treatment 
of infantile intestinal catarrh, are likewise useful for the enteritis and 
colitis of childhood, the quantity of the opiate, which is the important 
ingredient, being increased according to the increase in the age. The 
following formulas may be employed for a child of five years : — 

R. Pulv. opii, gr. v ; 

Bismuth, subnitrat., 5ij« Misce. 
Divid. in pulveres No. xx. Give one powder every two to four hours. 

R. Pulv. ipecac, comp., 5j ', 

Bismuth, subnitrat., 3ij- Misce. 
Divid. in pulveres No. xxiv. Give one powder as above. 

R. Tine, opii deodorat., gtt. xiviij ; 
Bismuth, subnitrat., gij ; 
Aq. menth. piperit., 
Syr. zingiberis, aa §j. Misce. 
Shake bottle. Give one teaspoonful from two to four hours. 

The local treatment which is found most useful consists in the use of 



656 CHOLERA INFANTUM. 

emollient applications covered with oil-silk, and made sufficiently irritating 
by mustard or otherwise to cause constant redness. 

If there are symptoms threatening convulsions, a mustard foot-bath 
repeated occasionally will usually tranquillize the nervous system and 
avert the danger. 

The diet should be bland and unirritatino-. In the first stages of the 
inflammation, rice or barley-water, or arrowroot boiled in water, and sim- 
ilar drinks should constitute the main diet. When the active inflamma- 
tion has abated, and at any period of the disease if there is a tendency to 
prostration, more nourishing food should be given. Milk and animal 
broths may then be allowed. In cases which are protracted, or attended 
with symptoms of exhaustion, alcoholic stimulants are required. 



CHAPTER X. 

CHOLERA INFANTUM. 



Cholera infantum, or, as it is sometimes called, choleriform diarrhoea, 
is a disease of the summer months; and with exceptional cases, of the 
cities. It receives the name which designates it from the violence of its 
symptoms, which closely resemble those in Asiatic cholera. It is, how- 
ever, quite distinct in its nature, occurring independently of the epidemics 
of that disease. 

I have elsewhere stated that, as regards at least this city, the term cholera 
infantum has been so extended as to embrace a large part of the diarrhoeal 
maladies affecting infants in the summer months. Some physicians apply 
it even to mild but protracted cases of ordinary non-inflammatory or in- 
flammatory diarrhoea occurring in the season mentioned. I employ it, 
and it should, in my opinion, only be employed, to designate that form of 
infantile diarrhoea in which there are frequent watery stools, accompanied 
by vomiting, great elevation of temperature, and rapid and great emaciation. 

The number of deaths from cholera infantum reported in our bills of 
mortality is so large, while the number from the same disease embraced in 
the death statistics of European cities is so small comparatively, that some 
have been led to believe that this malady is much more prevalent and 
fatal in this country than in Europe, whereas, were these terms employed 
in all places to designate precisely the same disease, probably no great 
difference would be found in the prevalence of cholera infantum on the 
two sides of the Atlantic. 

Causes.. — It has been stated that cholera infantum prevails mainly in 
the cities and in the summer months. Cases occur from the month of May 



SYMPTOMS. 657 

to October. Its maximum frequency and severity correspond with the 
degree of heat, and it is therefore most prevalent in the months of July 
and August. One of the chief causes of this disease is, doubtless, residence 
in an atmosphere loaded with noxious vapors, especially gases arising from 
animal and vegetable decomposition, or an atmosphere rendered impure 
by overcrowding and by personal and domiciliary uncleanliness. It is, 
therefore, much more common in tenement houses and parts of the city 
occupied by the poor than in cleaner and less crowded streets and apart- 
ments. 

Summer heat and the anti-hygienic conditions to which it gives rise in 
the cities, sometimes appear to be sufficient in themselves to develop cholera 
infantum ; at least it occurs without other obvious cause. In other, and 
probably the majority of cases, another cause co-operates, namely, the use 
of improper food. Atmospheric heat and its depressing influences are then 
predisposing causes, while the use of indigestible or irritating food is the 
exciting cause. Infants upon whom both causes are operative are most 
liable to cholera infantum in its severe form. Hence bottle-fed infants of 
the city are especially liable to it, and infants whose food is carelessly and 
improperly prepared. Often in the hot months, acid and indigestible 
fruits, as currants, heedlessly given to an infant, occasion the attack. 

Cholera infantum occurs commonly under the age of two years. It is 
so frequent during the period of first dentition, that some writers consider 
dentition a cause. At this period, however, as has been stated elsewhere, 
there is great functional activity, and rapid development of the intestinal 
follicles, and the peculiar liability to cholera infantum at this age should 
be attributed to this cause rather than to dentition. 

Symptoms. — Cholera infantum sometimes commences abruptly, the 
previous health having been good. In other cases it is preceded by a pre- 
monitory stage, that of diarrhoea. The stools are thinner than natural, 
and somewhat more frequent, but not such as to excite alarm. Suddenly 
the evacuations become more frequent and watery, and the parents are 
surprised and frightened by the rapid sinking and real danger of the in- 
fant. Occasionally this antecedent diarrhoea has continued several weeks, 
attended with emaciation and associated with intestinal inflammation. 

This disease is characterized by the discharge of thin stools, designated 
by some watery, by other serous. The first evacuations, unless there has 
been previous diarrhoea, contain considerable fecal matter. They are so 
thin as to soak into the diaper like the urine, and in some cases they 
scarcely produce more of a stain than does this secretion. The odor is 
peculiar, not fecal, but musty and offensive ; occasionally the stools are 
almost odorless. Commencing simultaneously with the watery evacuations, 
or soon after, is another symptom, namely, irritability of the stomach, 
which increases, greatly the prostration and danger. Whatever is swal- 
lowed by the infant is rejected immediately, or after a few minutes, or 
42 



658 CHOLERA INFANTUM. 

there may be retching without vomiting. The appetite is lost, and the 
thirst is intense. Cold water, especially, is taken with avidity, and if the 
infant nurses, it eagerly seizes the breast, in order to relieve the thirst. 
The tongue is moist at first, and clean or covered with a light fur. The 
pulse is accelerated, while the respiration is either natural or somewhat 
increased in frequency ; the surface is warm, but its temperature is speedily 
reduced. There is no disease of infancy in which the temperature of the 
blood is higher. In ordinary cases the thermometer introduced into the 
rectum rises above 105°, and I have seen it indicate 107^°. There is no 
abdominal tenderness, and no evidence of pain. The infant is often rest- 
less at first, but its restlessness is due to thirst, or that unpleasant sensation 
which the sick experience when the vital powers are rapidly reduced. The 
urine is scanty in proportion to the gravity of the attack. 

The loss of strength and the emaciation are more rapid than in any 
other diarrhoeal malady, except Asiatic cholera, and the most severe form 
of cholera morbus. The parents scarcely recognize in the changed and 
melancholy aspect of the infant any resemblance to the features which it 
exhibited a day or two before. The eyes are sunken, the eyelids and lips 
are permanently open from the feeble contractile power of the muscles 
which close them, while the loss of the fluids from the tissues and the 
emaciation are such that the bony angles become more prominent, and 
the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in two 
or three days, the infant remains quiet, not disturbed even by the flies 
which alight upon its face. The limbs and cheeks become cool ; the eyes 
bleared, pupils contracted, and the urine scanty or suppressed. As death 
draws near the respiration becomes accelarated from the pulmonary con- 
gestion consequent on the feeble contractile power of the heart, the pulse 
becomes more and more feeble, the surface has a clammy coldness, and 
stupor results, which becomes more and more profound, and from which it 
is impossible to arouse the infant. 

In the most favorable cases cholera infantum is checked before the oc- 
currence of these fatal symptoms. And often even in cases which are ulti- 
mately fatal, there is not such a speedy termination of the malady. The 
choleriform diarrhoea abates, and the case becomes one of ordinary entero- 
colitis as described in the foregoing pages. 

Anatomical Characters Rilliet and Barthez, who of foreign writers 

treat of this disease at greatest length, describe it under the name of gastro- 
intestinal choleriform catarrh. " The perusal," they remark, " of the ana- 
tomico-pathological description, and especially the study of the facts, show 
that the gastro-intestinal tube in subjects w T ho succumb to this disease may 
be in four different states : (a), either the stomach is softened without any 
lesion of the digestive tube ; (b), or the stomach is softened at the same 
time that the mucous membrane of the intestine, and especially its follicu- 



SYMPTOMS. 659 

lar apparatus, is diseased ; (c), or the stomach is healthy whilst the follicu- 
lar apparatus, or the mucous membrane, is diseased ; (rf), or, finally, the 
gastro-intestinal tube is not the seat of any lesion appreciable to our senses 
in the present state of our knowledge, or it presents lesions so insignificant 
that they are not sufficient to explain the gravity of the symptoms. 

" So far the disease resembles all the catarrhs, but what is special is the 
abundance of the serous secretion, and the disturbance of the great sympa- 
thetic nerve. 

" The serous secretion, which appears to be produced by a perspiration 
(analogous to that of the respiratory passages and of the skin) rather than 
by a follicular secretion, shows, perhaps, that the elimination of substances 
is effected by other organs than the follicles ; perhaps, also, we ought to see 
a proof that the materials to eliminate are not the same as in simple catarrh. 
Upon all these points we are constrained to remain in doubt. We content 
ourselves with pointing out the fact." 

American writers divide cholera infantum into three stages, the first 
characterized by turgescence of the intestinal follicles, with more or less 
softening of the mucous membrane. In the second stage the mucous mem- 
brane of the intestines is vascular in patches and streaks, and somewhat 
thickened and softened, while the solitary glands and patches of Peyer 
present an inflammatory hyperemia, and occasionally certain of them are 
ulcerated. In the third stage the brain is involved. The cranial sinuses, 
veins, and capillaries of the brain are congested, and there is transudation 
of serum upon the surface of the brain or in the ventricles. The following 
observations show the character of these lesions : — 

On the 1st of August, 1861, I made an autopsy of an infant sixteen 
months old, who died of cholera infantum, witli a sickness of less than one 
day. The examination was made thirty hours after death. Nothing un- 
usual was observed in the brain, except, perhaps, a little more than the 
ordinary injection of vessels at the vertex ; no disease of stomach and in- 
estines except enlargement of the patches of Peyer as well as the solitary 
glands ; mucous membrane pale. In this and the following cases there 
was apparently slight softening of the intestinal mucous membrane ; but 
whether it was pathological or cadaveric is uncertain, as the weather was 
very warm. The liver seemed healthy. Examined by the microscope, it 
was found to contain about the normal amount of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, 
who died July 26, 1862, after a sickness also of about one day. He was 
previously emaciated, but without any definite ailment. The post-mortem 
examination was made on the 28th. The brain was somewhat softer than 
natural, but was otherwise healthy. There was no abnormal vascularity 
of the membranes of the brain, and no serous effusion within the cranium. 
The mucous membrane of the intestines was of normal appearance through- 



660 CHOLERA INFANTUM. 

out, unless somewhat thickened and softened ; the solitary glands of the 
colon were enlarged. The patches of Peyer were not distinct. 

At the New York Protestant Episcopal Orphan Asylum, an infant twenty 
months old, previously healthy, w r as seized with cholera infantum on the 
25th of June, 1864. The alvine evacuations, as is usual in this disease 
were frequent and watery, and attended by obstinate vomiting. Death oc- 
curred in slight spasms, in thirty-six hours. The exciting cause was ap- 
parently the use of a few currants, which were eaten in a cake the day be- 
fore, some of which fruit was contained in the first evacuations. The brain 
was not examined. The only pathological changes which were observed 
in the stomach and intestines were slightly vascular patches in the small in- 
testines, and an unusual prominence of the solitary glands in the colon. 
These glands resemble small beads imbedded in the mucous membrane. 
The lungs in the above cases were healthy, excepting hypostatic conges- 
tion. 

Since the dates of these autopsies, I have made others in cases which 
terminated fatally after a brief duration, and have uniformly found similar 
lesions, namely, the gastro-intestinal surface either without vascularity or 
scantily vascular in streaks or patches, sometimes presenting a whitish or 
soggy appearance, and somewhat softened, while the solitary glands were 
enlarged so as to be prominent upon the surface. In cases which continue 
longer, evident inflammatory lesions soon appear, which are identical with 
those already described in the article which relates to intestinal inflam- 
mation. 

Nature. — It was formerly my opinion that cholera infantum is essen- 
tially non-inflammatory, but that it soon became inflammatory if not 
checked. Careful observations of its symptoms and lesions have since 
convinced me that it is the most violent inflammation to which infants are 
liable in our climate. There is no other infantile malady in which there 
is uniformly so high a temperature, and under which patients sink more 
rapidly. The alvine discharges to which the rapid prostration is largely 
due, probably consists in part of intestinal secretions, and in part of serum 
which has transuded from the capillaries of the intestines. It is well 
known to pathologists, that in inflammation of mucous surfaces of short 
duration, the redness is apt to disappear in the cadaver. 

The opinion has been expressed by certain observers that cholera in- 
fantum is identical with thermic fever or sunstroke. There is, indeed, a 
resemblance as regards certain important symptoms. In cholera infantum 
the temperature is from 105° to 108° ; in sunstroke it is also very high, 
often rising above 108°. Great heat of head, contracted pupils, thin 
fecal evacuations, embarrassed respiration, scanty urine, and cerebral 
symptoms are common towards the close of cholera infantum, and they 
are the prominent symptoms in sunstroke. Nevertheless, I cannot accept 
the theory which regards these maladies as identical, and which remove 



DIAGNOSIS — PROGNOSIS. 661 

cholera infantum from the list of intestinal diseases. In cholera infantum 
the gastro-intestinal symptoms always take the precedence, and are, except 
in advanced cases, always more prominent than other symptoms. It does 
not commence as by a stroke like coup de soleil, but it comes on more 
gradually though rapidly, and it often supervenes upon a diarrhoea or 
some error of diet. In the commencement of cholera infantum the infant 
is not apt to be drowsy, and it is often wide awake and restless from the 
thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke 
only occurs during the hours of excessive heat, but cholera infantum may 
occur at any hour, or in any day during the hot weather, provided that 
there is sufficient dietetic cause. Again, intestinal inflammation is not 
common in sunstrake, while it is the common, or as I believe the essential, 
lesion of cholera infantum. These facts show, in my opinion, that the 
two maladies are essentially and entirely distinct. Nevertheless, cases of 
apparent sunstroke sometimes occur in the infant, and if the bowels are at 
the same time relaxed the disease is apt to be regarded as cholera infantum, 
and if fatal is usually reported as such to the health authorities. Such cases 
I have occasionally observed, or they have been reported to me, although 
they are not common. 

With the exception of the organs of digestion, no uniform lesion is ob- 
served in any of the viscera, unless such as is due to change in the quan- 
tity and fluidity of the blood, and its circulation. Writers describe an 
anaemic appearance of the thoracic and abdominal viscera, and occasional 
passive congestion of the cerebral vessels. The cerebral symptoms often 
present towards the close of life in unfavorable cases of cholera infantum 
may arise from that state of the brain known as spurious hydrocephalus, 
which is not attended by any uniform or certain lesion of this organ. As 
the urinary secretion is scanty or suppressed, cerebral symptoms may be in 
certain cases be due to uraemia. 

Diagnosis This disease is diagnosticated by the symptoms, and es- 
pecially by the frequency and character of the stools. The stools have 
already been described as frequent, often passed with considerable force, 
deficient in fecal matter, and thin, so as to soak into the diaper almost 
like urine. The vomiting, thirst, rapid sinking, and emaciation serve to 
distinguish cholera infantum from other diarrhoeal maladies. 

When Asiatic cholera is prevalent, the differential diagnosis of the two 
diseases is difficult if not impossible. 

Prognosis — This is one of those diseases in regard to which physicians 
often injure their reputation by not giving sufficient notice of the danger, 
or even by expressing a favorable opinion, when the case soon after ends 
fatally. A favorable prognosis should seldom be expressed without quali- 
fication. If the urgent symptoms are relieved, still the disease may con- 
tinue as an ordinary intestinal inflammation, which, in hot weather, is 
formidable and often fatal. If the stools become more consistent and less 



662 CHOLEEA INFANTUM. 

frequent, without the occurrence of cerebral symptoms, while the limbs 
are warm and pulse good, we may confidently express the opinion that 
there is no present danger. 

The duration of true cholera infantum is short. It either ends fatally, 
or it begins soon to abate and ceases, or it continues as an entero-colitis. 
Death may occur, in twenty-four or forty-eight hours, in a state of collapse, 
from the frequency of the stools, or not till after three or four days. In 
general, if the case do not end within three or four days by recovery or 
death, it becomes one of severe ordinary entero-colitis. 

Treatment Cholera infantum requires beyond most other diseases, 

the employment of proper remedial measures, from the earliest possible 
moment, since the infant rapidly sinks, unless the evacuations from the 
bowels are arrested, or are rendered less frequent and watery. Regarding 
the disease as a violent intestinal inflammation, we have no difficulty in 
determining the therapeutic indications. Those already recommended in 
our article relating to intestinal inflammation, are indicated, and to the 
full extent which the infant will bear, without causing too much stupor. 
An infant between the ages of eight and twelve months, should take one 
teaspoonful of the following mixture every two or three hours, till the 
vomiting and diarrhoea are controlled : — 

R. Tinct. opii, gtt. xvj ; 

Spts. auimon. aromat., 5 ss- j > 
Bismuth, suhnitrat., sjij ; 
Syr. simplic, ^ss. 
Mistur. cretse, |iss. Misce. 

An infant of six months can take one-half the dose, and one of three .or 
four months, one-third or one-fourth the dose. Instead of this, one of the 
equivalent mixtures which are recommended for the treatment of intesti- 
nal inflammation, may be given. If cerebral symptoms appear, as rolling 
the head, drowsiness, etc., I usually write the prescription without the 
opiate, and it may then be given more frequently if the case require it, 
while the opiate prescribed alone is given more guardedly and at longer 
intervals. 

There is danger in this disease of the sudden supervention of stupor, 
amounting even to coma and ending fatally. In these cases the stools are 
generally suddenly checked, and the opiate might aid in producing this 
result. In a few instances which I can recall to mind, where death occurred 
in this way, the friends believed that the melancholy result was hastened 
by the medicine. If the evacautions are partially checked and there are 
signs of stupor, the opiate should either be omitted or given less frequently. 
Explicit and positive directions to this effect should be given. Eligible 
preparations of opium for this disease are paregoric, tincture of opium, 
pulv. cretse comp. c. opio, and, if there is no irritability of stomach, Dover's 
powder. 



TREATMENT. 663 

Certain writers recommend the employment of a purgative as prelimi- 
nary treatment, in order to remove any irritating substance from the in- 
testines. But delay in the use of remedies to check the evacuations involves 
too much risk. When the urgent symptoms are somewhat controlled, a 
moderate dose of castor oil may be prescribed if there is reason to suspect 
that there is any irritating substance in the intestines. 

By this mode of treatment the stools are generally in a few hours ren- 
dered less frequent and more consistent. 

There are physicians who believe that calomel in small and repeated 
doses has a beneficial effect in choleriform diarrhoea, but those who use it 
employ it in combination with opium, and it is probable that the good 
effect observed is mainly due to the latter remedy. From the anatomical 
characters of cholera infantum there is apparently no indication for a 
medicine that affects the function of the liver, and there is no evidence 
that calomel exerts any good effect on the follicular apparatus of the in- 
testines, which, so far as we can localize the disease, seems to be most in 
fault of any part of the digestive apparatus. On theoretical gounds, there- 
fore, I should oppose the employment of this agent, and my observations 
of its effects have been such that I entirely discard its use while we have 
other safe and efficient remedies to meet every indication. 

Ordinarily, as the diarrhoea is relieved, the vomiting ceases. The rem- 
edies employed for the former are also curative of the latter ; still the 
vomiting, if frequent and obstinate, sometimes does require special treat- 
ment, and there are no better anti-emetic mixtures than those recom- 
mended in our remarks on the treatment of intestinal inflammation. In 
robust infants, at the commencement of the attack, small pieces of ice 
taken in the mouth aid in diminishing the irritability of stomach. Mus- 
tard should also be applied to the epigastrium. 

In most cases alcoholic stimulants are required. The best of these is 
Bourbon whiskey or brandy, which should be used from an early period 
of the disease. Aside from its sustaining the vital powers, it aids also in 
relieving the irritability of stomach. 

The diet in cholera infantum should be simple but nutritious. That 
recommended for intestinal inflammation is proper for infants with this 
malady. 



66± INTESTINAL WORMS, 



CHAPTER XI. 

INTESTINAL WORMS. 

- The belief has been prevalent in the profession in former times,- and is 
now among the people, that worms in the intestines constitute a frequent 
disease, especially in children. As pathology and the means of diagnosti- 
cating diseases are better understood, this idea has been gradually aban- 
doned by physicians and the intelligent portion of the community. Still 
these parasites must be considered an occasional cause of serious derange- 
ments, and, in rare instances, a cause even of death. They indeed often 
exist in small number, without producing any appreciable deviation in the 
individual from the healthy state ; but the most common and best known 
species, when they have once effected a lodgment in the intestines of man, 
ordinarily grow and multiply so as to produce symptoms, and require 
medicines for their expulsion. 

So far as is now ascertained by observations in different countries, 
about fifty animal parasites make their abode in man. It is not improba- 
ble that the number will yet be found greater by observations in distant 
uncivilized countries. Of these fifty, twenty-one reside in the alimentary 
canal (Heller), several of them being microscopic. Of those occupying 
the intestines only, the following species are specially interesting to the 
practising physician, on account of their relation — for the most part causa- 
tive — to certain pathological states, to wit : the ascaris lumbricoides, or 
round-worm ; the oxyuris vermicularis, or thread- worm ; the bothrioce- 
phalus latus, and three species of taenia, or the tape-worms, and the tri- 
chocephalus dispar, or whip-worm. 

Ascaris Lumbricoides The round-worm has a dingy reddish or yel- 
lowish-red color and a cylindrical form, tapering towards both extremities 
from the point of its greatest diameter, which is a little posterior to the 
middle. The dead worm is paler than the living. The anterior extremity 
is tipped with three lips, between which and the body is a circular groove. 
Between these three lips, anteriorly is the aperture of the mouth, from 
which the oesophagus extends to the distance of one-fourth to one-third of 
an inch. The intestine, which has a light brownish color, extends from 
the oesophagus to near the posterior extremity of the animal, where it 
terminates in the anus. The females are in numerical excess of the males, 
and their size is also greater. The shape of the worm is like that of the 
common earth-worm, from which it derives the name lumbricus, but it is 



INTESTINAL WORMS. 665 

somewhat more pointed and its color a paler red. The tail of the male 
worm is curved like a hook, while that of the female is straight. 

The total number of eggs contained in a fully developed female has 
been estimated at sixty millions. The eggs when immature are conical, 
and are attached to a longitudinal band; when mature they are oval, with 
dark granular contents and a strong double shell, and their diameter is 
about g^o of an inch. They are expelled in countless numbers with the 
feces, and at the time of expulsion are surrounded by an albuminous coat- 
ing stained with bile. Their vitality is retained under apparently very 
unfavorable circumstances, even for years. They hatch even after they 
have been repeatedly frozen or desiccated. 

The ascaris lumbricoides inhabits the small intestines, where it is 
rapidly developed from the embryonic state. The remark made by 
Heller, that when found in the colon it is always dead, cannot be true, for 
many live worms are expelled in the stools. 

The round-worm, more than all other intestinal worms, is inclined to 
wander away from its usual abiding place, namely, from the jejunum and 
ileum, producing symptoms of more or less gravity, referable to the part 
over which it crawls. It occasionally enters the stomach, from which it 
is vomited, or it ascends the oesophagus into the fauces, from which it is 
soon removed by the eiforts of the individual. Cases are on record, one 
of which Andral witnessed, in which the worm entered the larynx, pro- 
ducing suffocation and speedy death. M. Tonnelle also witnessed such a 
case. A child, nine years old, was suddenly seized with great difficulty 
of respiration and pain in the upper part of the chest. A careful exam- 
ination of the thorax gave a negative result. Deatli occurred in from 
twelve to fifteen hours, and at the post-mortem examination a lumbricus 
was found filling the cavity of the larynx. M. Blandin, also, witnessed a 
case, when interne of the Hopital des Enfants. An infant was suffocated 
by one of these worms, which had penetrated as far as the right bronchus. 
Very rarely they crawl from the fauces into the nasal passages. This 
worm is so strong and active that there is no recess or reflexion of the 
mucous membrane of the digestive apparatus which it could possibly pen- 
etrate, in which it has not been found. It has been discovered in the 
appendix vermiformis, in the pancreatic duct, in the common bile-duct, 
and even in the gall-bladder. The number of these worms found in the 
intestines is very various. There may be only one, or the number may 
be almost incredibly large. 

Thus, Barrier relates the case of an infant thirty months old, w r ho died 
in Hopital Xecker. It was believed to be tubercular. Numerous tumors, 
which could be felt in the abdomen, were supposed to be tubercular 
masses. On making the post-mortem examination, the mesenteric glands 
were found healthy, but the intestines throughout their entire extent were 
filled with lumbrici. The masses which, during life, were believed to be 



66Q INTESTINAL WOEMS. 

tubercular glands, were found to consist of worms. The csecum, espe- 
cially, was greatly distended by them. The intertwining or collection in 
balls of these worms constitutes, indeed, one of the chief dangers, as it 
renders them so much the more difficult of expulsion. 

The round-worm possesses no organs of penetration, still, if the intestine 
is weakened by disease, especially by ulceration, it may, by pressure with 
its head, force an opening through which it escapes into the cavity of the 
abdomen, causing peritonitis and death. This worm is commonly found, 
whether single or in masses, surrounded with mucus, which serves as a 
partial protection to the intestines. 

The portion of the mucous membrane in contact with lumbrici is often 
found inflamed, either from movements of the worm, or from pressure of a 
mass of worms, or even of a single worm in a confined position, as the 
appendix vermiformis. This inflammation, continuing and increasing, 
may end in ulceration, and thus a weakened spot be produced, which may 
be ruptured by simple pressure of the mouth of the worm. In this way 
are to be explained those apparent cases of perforation, which have led 
some observers to believe that lumbrici had actually the power of pene- 
trating the healthy coats of the intestines. The perforation is obviously 
most apt to occur in those who have been enfeebled, and whose tissues 
have been rendered less firm and resisting by antecedent disease, as by 
typhoid fever. 

M. Guersant describes a case in which the appendix vermiformis con- 
tained an ulcerated opening, through which two round-worms had partly 
passed into the abdominal cavity, producing fatal perityphlitis. The effect 
of their impaction in this narrow cul-de-sac was much like that of a bean 
or seed lodged in the same situation. 

The ascaris lumbricoides has occasionally been found in the most re- 
markable locations, namely, in abscesses lying without the intestines. 
They have been known to effect a lodgment in the liver, and produce an 
abscess there, no doubt, by crawling up and distending a bile-duct. Their 
lodgment in other viscera, which have no pervious connections with the 
intestinal tract, is no doubt accomplished through fistulous openings pro- 
duced by inflammation which they had no part in causing, as, for example, 
in the bladder and kidneys, of which there are well-authenticated cases. 
Worm cysts in the abdominal walls have been found to occur in most in- 
stances in the usual site of hernias, namely, at the umbilicus in children, 
and in the inguinal region in adults. It is presumed, therefore, that the 
worms had entered hernial protrusions, from which they had passed by 
ulceration into the abdominal walls, and had there become encapsulated. 

The oxyuris vermicularis, or thread-worm, so called from its resemblance 
to pieces of ordinary white sewing thread, is also frequent in childhood, 
and is not infrequent in the adult. The length of the male oxyuris is 
from one-sixth to one-fifth of an inch : that of the female from one-third 



INTESTINAL WORMS. 667 

to one-half of an inch. The posterior extremity of the male is blunt, and 
is curved, or rolled up towards the abdomen ; that of the female is slender 
and pointed like an awl. 

The head of this worm is relatively broad, from an unusual thickness or 
fulness of the cuticle, and the mouth, surrounded by " three nodular lips," 
is situated in the centre of the extremity. The oesophagus extends back- 
ward from the mouth, gradually growing larger, like the segment of a 
long and narrow cone, and ending in a globular enlargement, which has 
been designated the pharynx. From the pharynx the intestine runs in 
nearly a straight line through the worm. 

The eggs are numerous, so completely filling the interior of the female 
as to conceal the organs from view. They are flattened on one side, but 
are rounded or convex in other parts of their circumference. One end is 
more pointed than the other, as in the eggs of birds. Certain of the eggs 
in the mature female are seen to be undergoing segmentation, preparatory 
hatching, while others more advanced contain tadpole-shaped embryos, 
and others still contain worm-shaped embryos, either lying within the 
shells or protruding from them. The hatching and growth of this worm, 
which have been observed under the microscope, are very rapid under 
favorable circumstances. " I once," says Heller, " saw the metamorphosis 
from the tadpole-shaped embryo to the worm-shaped embryo completed in 
about one hour," but the usual time is longer. Leuckart saw oxyurides, 
one-fourth of an inch in length, fourteen days after the eggs had been 
swallowed. 

Oxyurides may be developed so rapidly from eggs swallowed in the 
ingesta, that they attain nearly or quite their full growth while still in the 
small intestines, so that, although their chosen residence is in the large 
intestines, some of them are not infrequently found in the ileum, and even 
in the jejunum, of full size and active. The part of the intestinal tract 
which the oxyurides prefer, and in which the largest colony of them re- 
side, is the caecum and appendix vermiformis, and not the rectum, as 
stated in most of the books, and in this situation, where, they have been 
little disturbed, their habits and the relative proportion of the sexes can 
be best observed. But they are ordinarily found both in the caecum and 
rectum in the same individual, and, indeed, upon all parts of the inter- 
vening surface of the colon. 

The number of oxyurides in the individual varies greatly. They are 
occasionally so numerous upon the intestinal surface that they resemble 
fur, and when they are so abundant they are commonly found above the 
ileo-caecal valve as well as below it. The males are smaller and appa- 
rently more fragile and perishable than the female. Therefore in the 
rectum and other exposed situations, there is a numerical excess of the 
females ; but in reflexions of the intestines, where they are securely lodged, 
as in the appendix vermiformis, no marked difference has been observed 



668 INTESTINAL WORMS. 

in the relative number of the two sexes. Since the males are more deli- 
cate, transparent, and smaller than the females, they are more apt to be 
overlooked in a hasty post-mortem examination. 

The term tape-worm is applied to several species of the taenia, and to 
at least two species of the bothriocephalus, but all except four, namely, 
the taenia solium, taenia saginata or medio-canellata, taenia elliptica or cu- 
cumerina, and the bothriocephalus latus, are rare in Europe and North 
America, and are therefore of little interest to the practising physician. 

The tape-worm is an hermaphrodite, each segment containing the two 
sexual organs. The head, or scolex, is small, about the size of a pin's head, 
and segment after segment is produced by a budding process from the 
head. The segments are attached to each other at their extremities, and 
each segment as it becomes further and further removed from the head, 
by the formation of new intervening segments at -the upper end of the 
chain, becomes also larger and more matured. The oldest segments 
having attained their full growth, are detached, and have an independent 
existence. A separation of the chain of segments at any point does not 
compromise the life of the parasite. If only the head remain uninjured 
the segmentation continues from it, and in time the former number of 
segments and former length of the chain are restored. This worm resides 
in the small intestines, the larger species sometimes extending from the 
upper part of the jejunum to near the ileo-caecal valve. 

The tcenia solium is developed from an embryo, known as the cysticercus 
cellulosae, contained in the muscles of the hog. It has also been found in 
some other animals, as the dog, deer, and polar bear. It is a vesicle, 
about the size of a pea or small bean, having a delicate cell wall, and is 
nearly spherical, except as its shape is changed by compression between 
the muscular fibres. At one point of the cell wall is a depression, attached 
to the inner surface of which, and lying within the cyst, is a whitish, pear- 
shaped, solid body, which is the head of the cysticercus, and is identical 
in appearance and character with the head of the taenia solium turned 
inside out. Many experiments have shown the close relationship of the 
cysticercus and taenia solium, that they are two forms of existence of the 
same parasite. Segments of the taenia solium have been repeatedly fed to 
pigs, and the cysticercus produced in their muscles, though in what way 
the ovum or embryo passes from the stomach to the muscles is not known. 
On the other hand, swine flesh containing cysticerci has been fed to crimi- 
nals who were soon to be executed, and after their death the taenia was 
found in their intestines. It is evident that this parasite occurs only in 
those who eat swine flesh, as sausages, either raw or but slightly cooked. 

The head of this species of taenia, which is about the size of a small 
pin's head, has at the top a conical protuberance, upon which is a corona 
of hooklets, arranged in two circles, the booklets of the outer circle being 
smaller than those of the inner. The projecting points, however, of the 



INTESTINAL WORMS. 669 

two rows fall together, forming one circle. The hooklets are inserted into 
depressions in the head, and many of them have fallen out in most speci- 
mens which we have an opportunity of examining. The depressions in 
which the hooklets are lodged are often dark from pigmentation. Back 
of the circle of hooks are four sucking disks, which the worm is able to 
protrude and move freely. When protruded they appear as small tuber- 
cles with slender pedicles. The neck, which is slender and about one 
inch in length, shows no markings from commencing segmentation, and it 
is succeeded by very small and delicate segments, which gradually increase 
in size as the distance from the head increases. 

The mature segments (proglottides) vary in size accordingly as they 
are in a state of contraction or relaxation. When relaxed, their length is 
about half an inch and breadth one-quarter of an inch. The genital 
organs are situated on the margin of each segment, a little posterior to 
the middle, and there is an alternation in their location between the right 
and left margins in the chain of segments. The uterus lies in the centre 
of the segment, forming a longitudinal straight line. From seven to 
twelve branches are given off from each side of the uterus, and these 
divide and subdivide like the branches of a tree. The male genital 
organs lie in the same aperture or pore in the margin of the segment, with 
which the uterus and ovaries connect. 

The eggs of the taenia solium are globular, with a diameter of about 
T ^Q-th of an inch, and with thick shells, which are striated like Mosaic 
work by lines which cross each other. It is estimated that not less than 
50,000,000 eggs are contained in all the segments of a matured tamia. 

This parasite is very liable to abnormal development. In some in- 
stances two or more segments are fused together, and often they are 
stunted in their growth, or they contain holes, fissures, and flaws, either 
from their original development, or produced by rupture of the distended 
uterus. Again, rarely two taenia are blended, so that along the flat side 
of one chain another is united by the margin, so that a section of the 
double parasite resembles the Roman letter T or Y. The nutrition of the 
segments is maintained through a vessel running the whole length of the 
worm, near each margin, and having communicating branches. 

The tcenia saginata, designated also medico-canellata, is much larger, 
stronger, and thicker, both as regards the head and segments, than the 
taenia solium. When fully matured it measures eighteen feet. The di- 
ameter of the head is nearly one line (yg^ inch). It is furnished with 
four strong sucking disks, but it lacks the. circlet of hooks which charac- 
terizes the taenia solium. Instead of the hooks the head is furnished Avith 
a small frontal sucking disk. The heads of some specimens of this worm 
are free from pigment, but other specimens present various shades of pig- 
mentation — from a slight staining to a jet black color. The neck is short, 
and very near the head are markings which indicate commencing segmen- 



670 INTESTINAL WORMS. 

tation. The matured segments vary in measurement when relaxed — from 
a length of eight lines and breadth of two lines, to a length of nine lines 
and breadth of three lines. As in the taenia solium the genital pores are 
situated on the margins of the segments, varying irregularly from side to 
side, and the uterus has lateral branches, which divide dichotomously. 
There is but little difference in the sexual apparatus of the taenia solium 
and taenia saginata, but the eggs of the latter are somewhat larger than 
those of the former, and are oval. 

The development of the taenia saginata is sometimes irregular, producing 
monstrosities, as in the taenia solium. The embryos of this parasite occur 
chiefly in the muscles of ruminating animals, as the ox, sheep, goat, etc., 
and therefore its presence in man is attributable to the use of the flesh of 
these animals, either slightly cooked or raw. The cysticercus of this 
species appears to be less tenacious of life than that of the taenia solium, 
and when it perishes it becomes changed into a greenish -yellow pulp, sur- 
rounded by the capsule, and imbedded in the muscular or other tissue 
where it had lodged. 

It is easy to distinguish this worm from the taenia solium if the head is 
found, by its larger size, the larger size of its sucking disks, and the ab- 
sence of the circle of hooks. The segments are distinguished by their 
greater size, and the greater number, and the dichotomous division of the 
branches of the uterus. This species occurs over a much greater area of 
the earth's surface than the taenia solium. 

The tcenia elliptica or cucumerina is a more delicate worm than the 
preceding species, measuring, when fully grown, from seven to ten or ele- 
ven inches in length. Upon its head is a rostellum or beak, which the 
worm is able to thrust forward, and on which are about sixty hooks, irregu- 
larly arranged. The anterior portion of the parasite is very delicate, like 
a thread, and its segments are small, but as in the other species they be- 
come larger, as their distance from the head increases. The matured 
segments which have a reddish-white color are readily detached, and when 
separated they move about actively. This taenia is also an hermaphrodite, 
and a genital pore containing a double set of genital organs is located on 
each margin of the segment. The taenia elliptica inhabits the small intes- 
tines of the dog and cat, and many children in different localities have 
been affected with it. 

Heller states that the segments of another and rare species of taenia, 
which were expelled from a child of nineteen months, are preserved in the 
Museum of Pathological Anatomy in Boston. Nearly in the middle of 
the posterior half of each segment, is a yellow spot, namely, the receptacu- 
lum, full of ova, and, therefore, the name flavo-punctata has been applied 
to this worm. Little is known in regard to the taenia nana and taenia 
Madagascariensis, since they occur in distant countries. 

The bothrhcephalus latus is the largest of the tape-worms, attaining 



INTESTINAL WOEMS. 671 

the length of 15 to 24 feet. It is one of the most important of the intes- 
nal parasites. The head has an almond-shape, or the shape of an elon- 
gated, and somewhat flattened globe, its length being about one line, 
and its diameter from one-third to one-half a line. Eimning longitudi- 
nally along each flattened side of the head is a groove or fissure, contain- 
ing the apparatus of suction. Those segments, which are still in the pro- 
cess of growth, have a breadth three or four times greater than their length, 
while the matured segments are nearly square. The genital pore occurs 
in the centre of one side of the segment, and in the chain of segments all 
the pores are found on the same side. A brownish, rosette-shaped spot is 
observed at the site of each ripe pore produced by the convolutions of the 
uterus, and the numerous eggs which this organ contains. 

The egg, which is oval, has a thin shell, a light-brown color, and at one 
end of it is a lid or operculum, which is separated from the rest of the egg 
by a well-defined line. At the hatching an embryo, provided with six 
hooks, escapes from the lid. When it has separated from the egg it is 
provided with an albuminous covering, from which cilia radiate in all di- 
rections, by the movement of which it is propelled. After a few days this 
covering is lost, and the embryo now moves about by amoeboid extension 
and contraction. It is believed that in this embryonic state it enters an 
aquatic animal, a mollusk or fish, where it undergoes further develop- 
ment, and from which it is received into the stomach in the food. The 
bothriocephalus occurs not only in man, but also in some of the domestic 
animals, which eat fish, as the dog. This parasite is believed to be rare 
outside of Europe, and in Europe it is chiefly met in countries bordering 
on inland lakes and seas. 

The trichocephalus dispar is comparatively unimportant to the physician, 
since it is uncertain whether it materially impairs the health or produces 
symptoms. It inhabits the caecum, but in rare instances it has been found 
in the ileum and appendix vermiformis. The number of these parasites 
is usually small, but as many as seventy to one hundred have been ob- 
served in the intestine of the adult. 

The trichocephalus dispar occurs also in the monkey, and a very similar, 
if not identical worm, has been found in the pig. It is not frequent in 
children, and it has not been observed in very young children. It occurs 
in man in every part of the globe, and in some countries as Egypt, Nu- 
bia, and Syria, it is said to be very common. This worm, which is also 
sometimes designated the whip-worm from its shape, attains the length of 
one and a half to two inches, the female being longer than the male. Its 
anterior two-thirds are thin, delicate, and flexible, like a small thread. 
The posterior one-third which contains the generative organs, and intesti- 
nal canal is considerably thicker, and it ends abruptly. On the under 
surface, extending nearly the whole length of the body, is a longitudinal 
band, the width of which is about one-third the circumference of the body. 



672 INTESTINAL WORMS. 

In the female, the posterior or thick portion of the worm is slightly bent 
or curved like the stock of a hunting whip, while that of the male is rolled 
in the spiral form. The digestive tube consists of an oesophagus, which 
extends through the anterior thread-like part, and the stomach and 
rectum which lie in the posterior thick division. The genitals of the 
female lie in the commencement of the thick portion, and the uterus, when 
distended with eggs, occupies nearly the whole of this section. In the 
male, the pore, which contains the genitals, lies in the posterior extremity 
of the thick part where it forms a cloaca with the termination of the in- 
testinal canal. The eggs, which are numerous, are oval, brownish, and 
with a glistening protuberance at each extremity, giving them the shape 
of a lemon. They have great vitality, hatching after repeated desicca- 
tion and freezing. Their development from the egg is slow. It is be- 
lieved that the trichocephalus is produced directly from the egg, which has 
lodged in the intestine, and, therefore, does ■ not have or require an inter- 
mediate stage of preparation in another animal. This parasite resides in 
the caecum, but when many are present, some are found in the ascending 
colon, and occasionally a few are observed in the small intestine. 

The taenia is rare in early life, but cases now and then occur. 1 have 
met very few cases in this city under the age of five years. Rosen and 
Bremser report cases between the ages of six and eleven years, and Hufe- 
lancl one at the age of six months. Wawruch collected 206 observations 
of taenia, in 22 of which the age was less than fifteen years ; the youngest 
was a girl of three years. A most remarkable case of taenia is reported 
in the Gazette Medicale of Paris in 1837. M. Muller was called to treat a 
foster child five days old for slight constipation. The bowels were evacuated 
by the use of rhubarb, manna, and a few grains of salt, and in the excre- 
ment a foot and a half of taenia were discovered. This worm had evidently 
existed during the foetal life of the infant. 

A similar case was treated by Prof. Skene, in the Long Island Hospital, 
in September, 1871, and reported by Dr. Armor, in the New York Medical 
Journal. The infant was born September 3d, of a hearty Irish servant 
o-irl. On the 7th it refused to nurse, and was observed to have a mild form 
of tetanus. On the 8th small doses of calomel having been given, followed 
by castor oil, two segments of a taenia solium were passed from the bowels, 
and on subsequent days ten more segments, after which the tetanus .ceased. 
The remedies employed after September 8th were the oil of male fern and 
turpentine. The mother, who had presented no symptoms of taenia, was 
ordered an emulsion of pumpkin- seeds, which "she faithfully took for 
twenty -four hours, at the end of which she passed over seventy segments 
of taenia." This case is interesting as throwing light on a possible mode 
of the production of taenia, quite different from the ordinary and recog- 
nized mode, and also as showing the causative relation of intestinal worms 
to tetanus infantum. 



INTESTINAL WORMS. 673 

Causes. — It is obvious that intestinal worms are developed from eggs 
or embryo, which are introduced into the stomach in the ingesta. The 
eggs of the ascaris lumbricoides have been found by Mosler in drinking 
water ( Virchoiv's Arch., 1860), but it is probable that in most instances 
they are contained in fruits and vegetables which are eaten raw. The 
eggs of the oxyuris vermicularis are received from some one who is him- 
self affected with the disease. Both Zenker and Heller state that they 
have frequently discovered ripe eggs of this worm around the nails of per- 
sons who were troubled "with oxyurides, a fact readily explained from the 
itching which they cause. If these eggs are upon the fingers of the 
mother or nurse, it is easy to understand how they are acquired by the 
child. We can understand also why this worm is so common in degraded 
and filthy families. In reference to the etiology of the tape-worm nothing 
need be added to what has been stated above, and little is known in refer- 
ence to the manner in which the eggs of the tricocephalus are received. 

Certain conditions of the intestinal surface favor the occurrence of 
worms. Thus children in advanced typhoid fever are not unfrequently 
affected with the ascaris lumbricoides. 

Symptoms of the Ascaris Lumbricoides These are in part con- 
stitutional and in part local, due to the mechanical effect of the entozoa on 
the coats of the intestines. Writers, especially Rilliet and Barthez, have 
described the symptoms supposed to indicate lumbrici with minuteness. 
Those of a constitutional character are the following : Features at one 
time flushed, at another pallid, and in some children of a leaden hue ; 
lower eyelids swollen, and sometimes surrounded by a blue semicircle ; 
thirst, nausea, or even vomiting ; appetite diminished or augmented, or 
variable ; breath foul ; papilke of the tongue red and projecting ; pulse 
accelerated and irregular. Rilliet and Barthez state that they observed 
this irregularity in a boy three years old, at the time he was passing a 
large number of lumbrici. The irregularity afterwards disappeared. Ac- 
celeration of the pulse is one of the most common symptoms of these 
worms. The popular idea of " worm fever" has indeed a foundation in 
fact. This fever is often remittent and mild, but occasionally it is con- 
tinuous and of a high grade. 

The symptoms pertaining to the nervous system are important. In mild 
cases they may be absent, as when there are few lumbrici, and the child is 
robust, and over the age of five years, but in severe cases more or fewer 
of these symptoms are commonly present. They are dilatation of the 
pupils, especially inequality of dilatation, to which Munro attached diag- 
nostic value ; strabismus, twitching of the muscles, clonic convulsions, 
somnolence, headache, neuralgic pains, delirium. Rarely chorea, deafness, 
and paralysis, it is believed, may result. (M. Bouchut, Gaz. des Hopi- 
taux, 1867.) In the Amer. Journ. of Med. Set. for July, 1869, Dr. 
Leedom, of Montgomery County, Pa., relates the case of a boy of seven 
43 



674 INTESTINAL WORMS. 

years, who had night-blindness due to a large number of lumbrici in the 
intestines. By the employment of pinkroot and calomel these were ex- 
pelled, and the blindness ceased. Hyperesthesia of the abdominal surface 
was present in a case which I attended, and which subsided as soon as 
the lumbrici were expelled. Grinding the teeth in sleep, and picking 
the nostrils, are symptoms to which families attach great value. Obser- 
vations, however, show that, though sometimes due to worms, they more 
frequently have another cause. 

The local symptoms or disorders, in other words, those having a me- 
chanical origin, are colicky pains, experienced chiefly in the umbilical 
region ; stools sometimes natural ; in other cases diarrhoea with fecal or 
muco-sanguineous stools ; flatulence. M. Davaine, at a recent period, 
made the important discovery that the feces of patients affected with 
worms contain the ova of the particular species present, in large numbers. 
These ova, which have been described above, can be seen through a lens 
magnifying 150 diameters. 

In exceptional cases, there are local symptoms due to the presence of 
worms in unusual situations, such as a crawling sensation in the oesopha- 
gus ; a sense of constriction in this tube or the pharynx ; nausea and 
vomiting ; a cough, especially if the worm has crawled to the upper part 
of the oesophagus ; rarely the most urgent dyspnoea, and probable suffoca- 
tion, if a lumbricus has entered the larynx. Earache, and perhaps con- 
vulsions if the worm has entered the Eustachian tube (Case Davaine, p. 
144). The most dangerous symptoms indeed arise from the fondness 
which this worm exhibits of crawling through narrow openings. 

The enteritis and colitis, to which these worms sometimes give rise, is 
ordinarily mild, but in rare instances ulceration occurs, which may be 
attended by profuse and even fatal hemorrhage. Occasionally very pain- 
ful and dangerous constipation results from an accumulation of worms, in 
a ball or mass too large to be expelled, unless with much delay and suffer- 
ing, preventing the passage of fecal matter, and producing severe abdominal 
pains. The symptoms in these cases resemble closely those of intussuscep- 
tion. A marked example of constipation produced in this way occurred 
in a family with whom I am acquainted, and who then resided in the in- 
terior of this State. A little girl of three or four years was suddenly 
affected with obstinate constipation. The physicians prescribed active 
purgatives, calomel among others, and finally croton oil, and various in- 
jections, without relief. There was great pain with distension of the ab- 
domen, and death seemed inevitable, when, after the lapse of several days, 
a free evacuation occurred, and in the stool was a mass of worms firmly 
intertwined. 

Children often have lumbrici without any appreciable impairment of 
the general health, but their presence may intensify the symptoms of 
intercurrent diseases, and greatly increase the danger. Thus I recollect 



SYMPTOMS. 675 

two children of three and three and a half years, with pneumonitis, who, 
at the same time, had lumbrici, one passing in the course of a few days 
thirty and the other twelve of these encozoa. Both presented well-marked 
physical signs of pneumonitis, and, though they recovered, the febrile 
movement and nervous symptoms were apparently aggravated by the 
intestinal affection. One had convulsions in the commencement of the 
inflammation, followed by profound stupor and amaurosis, lasting two or 
three days. 

Often the symptoms due to lumbrici coexist with those of a protracted 
and distinct intestinal disease. Thus, as we have seen, the intestinal secre- 
tions of typhoid fever and of chronic diarrhoea! maladies afford a nidus 
for the growth of worms, and accordingly, at an advanced stage of these 
diseases, lumbrici are common. 

These symptoms produced by the oxyuris vermicularis are somewhat 
different. These worms do not usually cause the fever, disturbed diges- 
tion, the colicky pains, or the dangerous nervous symptoms which arise 
from the presence of lumbrici. !Nor do they, like lumbrici, endanger life 
by crawling into unusual situations. In one recent case, I could detect 
no other cause of chorea than the presence of oxyurides, and eclampsia 
has been attributed to them, but such a result is exceptional, if, indeed, 
the cause is rightly assigned. 

Although the caecum is the chosen abode of this worm, and here more 
than elsewhere it exists in its normal state, it is not certain that it pro- 
duces any appreciable symptoms in this part of the intestinal tract. 

The symptoms which render this the most annoying of all the intestinal 
parasites are produced by those oxyurides, chiefly the females, which de- 
scend into the rectum, where by their active movements they produce intense 
itching. A small number of worms cause little inconvenience, but when 
many are present in the folds of the rectum, their crawling produces such 
intense pruritus that the patient can with difficulty remain quiet. Usually 
this symptom is most marked in the early evening, when the child is 
warm in bed. It sometimes causes onanism in the girl as well as boy. 
This symptom may be nearly or quite absent during the day, but return 
so regularly at night as to resemble and be mistaken for a periodical ner- 
vous affection. So eminent a physician as Cruveilhier confesses that he 
has made this mistake of diagnosis. In the female child the oxyuris oc- 
casionally passes from the rectum to the vulva, producing leucorrhoea. 

In many instances tape-worms exist in children as well as adults, who 
thrive and present no symptoms, but in other instances there is more or 
less disturbance of the digestive function, with an uncomfortable sensation 
in the abdomen. This sensation is more noticed after fasting, or after the 
use of certain kinds of food, and it is diminished by a full meal. Great 
hunger and a feeling of faintness are also common according to authorities, 
but I have not particularly remarked this in children. Irregular action of 



676 INTESTINAL WORMS. 

the bowels, vomiting, and various nervous symptoms, as itching of the 
nostrils and anus, headache, tinnitus aurium, cardialgia, numbness, deafness, 
blindness, etc., have with more or less correctness been attributed to the 
tape-worm. Certainly such symptoms occasionally arise from this cause, 
for they cease with the expulsion of the worm (see case of Chorea, Medico- 
Chir. Rev., January, 18G8). Since the cysticercus cellulosee is the em- 
bryonic form of the tsenia solium, it is quite possible that individuals pos- 
sessing the latter may be infected from its ova with the former, so that 
symptoms which have been attributed to the intestinal parasite, have some- 
times been due to the encysted embryo. We are unacquainted with the 
symptoms of the trichocephalus if any occur, and this worm is very rare 
in children. 

Diagnosis Bremser long since made the remark, and it has been re- 
peated by most writers on diseases of children, that there is no sign or 
symptom which affords positive proof of the presence of intestinal worms, 
except the expulsion of one or more. Late microscopic investigations have 
revealed, however, a pathognomonic sign, namely the presence of ova in 
the feces, which indicate not only the nature of the disease, but the species 
of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them are present, and a careful examina- 
tion discloses no other cause, the presence of worms should be suspected, 
provided the child is over the age of two years. The microscope may then 
be used for diagnosis. A little tentative treatment, entirely safe to the 
child, will also determine whether the suspicion is correct. One or two 
doses of medicine, administered under such circumstances, like the sur- 
geon's exploring needle, may reveal the nature of the disease, and indicate 
the means of cure. 

In case of the oxyuris vermicularis, the itching directs attention to the 
anus as the place of the disease, and here the offending entozoa may often 
be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small 
proportion of cases. Oxyurides never prove fatal, unless in rare instances, 
through convulsions. The manner in which death may be produced by 
lumbrici has already been pointed out. 

In general, when the nature of the disease is ascertained, the worms are 
readily expelled by treatment, and the patient restored to health. If then 
there is no complicating disease, the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by parents 
before the physician is called. Medicines of this kind are usually irritants, 
and, in many of those diseases which simulate the verminous affection, but 
are distinct from it, there is already an irritated if not an inflamed state 
of the intestinal mucous surface. 



TREATMENT. 677 

Vermifuges administered under such circumstances obviously do harm, 
and in all acute diseases in which they are not required, even if their action 
is harmless, their employment is to be regretted, since it consumes time 
which is very precious. It is thus that many lives are lost by the use of 
anthelmintic nostrums, which are extensively advertised and which com- 
mand a ready sale, inasmuch as the belief in the presence of worms as a 
frequent cause of disease pervades all classes. 

A safe rule, followed by many physicians, and it would be much better 
if it were general, is not to give anthelmintics unless the child has passed 
one or more worms, or their ova are found in the feces, and not then if 
the symptoms seem to be referable to a coexisting disease. In doubtful 
cases in which the symptoms resemble those of worms, a purgative dose 
of calomel or calomel and rhubarb may be employed. It will generally 
bring away one or more lumbrici or a mass of ascaris vermicularis, if either 
species of entozoa is present. This purgative may be safely employed if 
there is no previous diarrhoea or debility. If after one two doses and 
a free purgation no worms are passed, anthelmintic remedies should not be 
given, for it is almost certain that no worms exist. 

A large number of medicines have, or have had, a reputation as anthel- 
mintics. Santonin, the active principle of the European wormseed, is one 
of the best, and is much employed in this country and in Europe. It is 
nearly tasteless ; it may be given in powder, spread on bread with the butter. 
It is kept in shops in one or two-grain lozenges, with and without calomel. 
It has the advantage of easy administration, and is destructive to both the 
round- and thread-worm. M. Bouchut considers it preferable to all other 
remedies in the treatment of the round-worm. " To children two years 
of age he administers it in doses of ten centigrammes (2.30 grains), and 
in patients above this age the quantity is increased by five centigrammes 
(1.15 grains) for every additional year." He gives in addition occasional 
doses of calomel or castor oil. In this country santonin is usually admin- 
istered in one to three-grain doses, two or three times daily, with an occa- 
sional purgative. The purgative is required to aid not only in the expul- 
sion of the worm, but also of the ova. In overdoses santonin causes 
vomiting, diarrhoea, and altered vision, so that objects appear yellow, but 
in medicinal doses it produces no unpleasant consequences. Other medi- 
cines are preferable if there are symptoms of enteritis. For many years 
the anthelmintic most employed in this country was the pinkroot, the root 
of the Spigelia marilandica, an indigenous plant. It was not only pre- 
scribed by physicians, but employed by families as a domestic remedy. 
It is apt to cause, if the dose is large, cerebral symptoms, as vertigo, 
dimness of sight, spasm of the facial muscles, stupor, and even convulsions. 
These effects less frequently occur if the pinkroot is given with a purga- 
tive, and it has been customary to administer it in combination with senna 



678 INTESTINAL WORMS. 

in an infusion. A half ounce of spigelia with an equal quantity of senna 
is macerated for two hours in a pint o: boiling water, and then strained. 
For a child two or three years old the dose is .half an ounce to one ounce. 
So popular has this vermifuge been in this country, that probably a ma- 
jority of the native-born adults in the States recollect the nauseating 
doses of pinkroot administered by anxious parents. Pharmacy now pro- 
vides us with the same medicine in a more convenient and acceptable 
form, that of the fluid extracts : — 

U. Fluid ext. spigeL, f^j ; 

Fluid ext. sennae, f §ss. Misce. 
One teaspoonful to a child from three to five years. 

The officinal fluid extract of spigelia and senna may be given in the 
same dose. Professor Procter recommended the addition of santonin to 
this extract : — 

R. Fluid ext. spigel. et sennse, f §j ; , 

Santonin, gr. viij. Misce. 

This is probably the best anthelmintic that can be employed for the 
destruction of the round-worm in uncomplicated cases, and it is also very 
useful in treating the ascaris vermicularis. Chenopodium is also a good 
anthelmintic. It is efficient, and at the same time one of the safest in 
case the mucous membrane is inflamed. If there is abdominal tender- 
ness, with stools too frequent, and thin, or mucous, and tinged with blood, 
I should prefer the chenopodium to most of the other vermifuges. To a 
child of three years five drops of the oil may be given three times daily. 
It may be continued for a longer period than Mould be safe for most of 
the other vermifuges. Twice a week, during its use, a mild purgative 
should be given, as castor oil, rhubarb, or magnesia, unless the bowels are 
open. It may be given dropped on sugar, or in a mucilaginous mixture. 

Dr. J. F. Meigs says : I myself rarely give any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has 
already been tried and failed. From my own experience, I believe that 
this remedy is all-sufficient in a large majority of the cases that occur in 
this city, as these are almost always of a mild character, and as it not 
only produces the expulsion of the parasites when they exist, but also 
acts beneficially upon the forms of digestive irritation which simulate so 
closely the symptoms produced by worms. I am persuaded, indeed, that 
of all the cases that have come under my notice, in which it seemed proba- 
-ble that worms might be present, none were expelled in nearly half, and 
yet the signs of disturbed health have passed away under the use of the 
remedy." . . . . " The following is a very good formula for the adminis- 
tration of this remedy : — 



TREATMENT. 679 

"R. 01. clienopodii, gtt. lx vel 5J ! 
P. g. acacia?, 3ij '■> 
Syrup, simplic., |j ; 
Aq. cinnamom., jfij. Misce. 
" Give a desertspoonful three times a day for three days, and repeat after several 
days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives rise 
to worms, turpentine is one of the best anthelmintics. In fact, in some 
of these cases there is no good substitute for it. For example, a boy of 
about ten years, attended by myself, October, 1864, had reached or nearly 
reached the fourth week of typhoid fever, when he passed from his bowels 
a large quantity of blood. He was previously emaciated and weak, and 
there had been, as is usual in such cases, considerable diarrhoea. The 
hemorrhage was attended with great prostration, from which, however, he 
partially rallied by the use of stimulants. On the following day an equally 
severe hemorrhage occurred, attended with coldness of the face and ex- 
tremities and great feebleness of pulse, so that death appeared imminent. 
Turpentine was now administered every six hours, a few lumbrici were 
passed, and the case thenceforth progressed favorably. The mechanical 
effect of the lumbrici on the ulcerated surface of intestine had probably 
given rise to the hemorrhage. Turpentine may be given in doses of from 
five to ten minims three times daily to a child five years old. Sweetened 
milk or sugar in powder is a good vehicle for it, or it may be given in a 
mucilaginous mixture. 

R. Spts. terebinth, rect., 5ij J 
01. limonis, gtt. v ; 
Mucil. gum acac, 
Syr. simplic, aa 3yj I 
Aq. anisi, §j. Misce. 
Dose, one teaspoonful every six hours. 

The following formula for the employment of this agent is recommended 
by Dr. Condie : — 

R. Mucil. gum acac, §ij ; 
Sacch. alb., 3 X ', 
Spir. aether, nitr., 3iij ; 
Spir. terebinth, rect., giij ; 
Magnes. calcinat., £)j ; 
Aquae mentha?, ]|j. Misce. 

It is useless to enumerate the many anthelmintic mixtures which have 
been extolled from time to time. Those mentioned above are the least 
nauseous, and will rarely disappoint the practitioner. One other antidote 
for the round-worm should be mentioned, as it has been much used and is 
efficient, namely, cowhage. This consist of the bristles which cover the 
pods of the Mucuna pruriens, a tropical plant. The pods are dipped in 



680 INTESTINAL WORMS. 

plain syrup of the ordinary consistence, and the bristles are scraped off 
with the syrup. When enough of the medicine is added to render the 
syrup of the consistence of thick honey, it is ready for use. The dose is a 
teaspoonful every morning for three days, after which a cathartic should 
be administered. I have never prescribed cowhage, although it is not in- 
frequently ordered by physicians, and a popular nostrum consists chiefly 
of it. 

One affected with tape-worm is obviously cured only when the head of 
the parasite is expelled ; but, in the majority of cases which I have ob- 
served, the head has not been found in the evacuations, even when the treat- 
ment had effected a complete cure, as shown by the subsequent history. 
The chain of expelled segments commonly terminated very near the head. 
This I believe is the common experience if we trust the friends of the 
patient with the examination of the stools. The physician himself should 
search for the worm's head, the evacuations being preserved, the nurse 
being directed to add a little carbolic or salicylic acid, and a sufficient 
quantity of water to nearly fill the vessel. The liquid should not be roughly 
stirred with a stick, as physicians are in the habit of doing, since this 
breaks the worm into small portions, and renders the inspection more dif- 
ficult, but it should be shaken frequently so as to detach the segments and 
head if, it be present, from the fecal matter. After it has stood at least 
five to ten minutes, the worm, which has greater specific gravity than 
water, sinks to the bottom, and the upper part should be poured off. This 
process must be repeated till the water is nearly colorless, after which 
search should be made for the fragments, and the head, if present, will be 
found. 

Since entire expulsion of the tape-worm is effected with difficulty, pre- 
paratory treatment for about forty-eight hours should be employed before 
the vermifuge is administered. During this time the patient should take 
a mild purgative once or twice, and such food, in moderate quantity, should 
be allowed as leaves little residuum, as beef-tea, milk, etc., with some stimu- 
lant, if the patient feels exhausted. There are three articles of food which 
experience has shown to be especially useful in this preparatory treatment, 
perhaps from a sickening effect which they produce upon the worm, namely, 
salt herrings, onions, and garlic. These may therefore be taken as food in 
the twelve or eighteen hours preceding the employment of the vermifuge, 
which it is ordinarily most convenient to administer in the morning. 

The various tsenicides recommended in the books are probably all more 
or less efficient, but the one which has given most satisfaction in the Out- 
door Department at Bellevue, where probably a larger number of these 
cases is treated than in any other place in this country, is the oil of male 
fern, but it is found necessary to employ a larger dose than is recommended 
in some of the books. For a child of six years the dose employed is one 
to two drachms in any convenient vehicle, as the syrupus aurantii florum. 



TREATMENT. 681 

This should be followed in about four hours by a dose of castor oil, which 
completes the treatment. Heller, a very high German authority, recom- 
mends koosso or its active principle koossin, in the use of which I have 
had no personal experience. The pumpkin-seed has also been employed 
at Bellevue and in other parts of this city, but it seems to be less efficient 
than the oil of the fern. If the chain of segments break near the head, 
and the head is not seen, it will be necessary to wait two or three months 
in order to determine whether the cure is complete. 

Since the symptoms produced by the oxyuris vsrmicularis are referable 
chietiy to the rectum, and are caused by the active movements of the 
worm, the prompt and thorough use of enemata, which causes their expul- 
sion, is evidently required. Enemata are more effectual if used cool than 
if warm, and since this worm inhabits the caecum as well as rectum, large 
enemata given through a long tube or a large catheter are more effectual, 
causing the expulsion of a larger number of worms than are expelled by 
small enemata employed in the usual manner. Various substances have 
been used for this purpose, as lime-water, table salt in water, turpentine 
in milk, decoction of aloe, decoction of garlic, etc. Heller says : " Simple 
water would do well for this purpose, for in a short time it causes the worm 
to swell up and burst ; but that is not altogether without an injurious effect 
on the intestinal mucous membrane. Hence, Yix recommends a solution 
of castile soap in distilled water, or rain water, of the strength of one to 
two and a half grains to the ounce. This has no unpleasant action on the 
intestinal mucous membrane, while at the same time it quickly destroys 
both the worm and their eggs Yix has tested all the medi- 
cines usually used in enemata, and has found the above solution of castile 
soap to be the most effectual." The use of the enema in the evening, 
although a small quantity of liquid is used so as to wash out the rectum, 
insures relief from the itching and sleeplessness during the night. 

But it is undeniable that enemata alone do not effect a complete and 
permanent cure in a large proportion of cases, and hence those affected 
with this worm remain sufferers for years, having only a temporary respite, 
unless medicines are administered by the mouth. Those medicines which 
produce free watery evacuations appear to be the most effectual in dis- 
lodging and expelling oxyurides whose attachment to the intestinal sur- 
face is not strong ; therefore Heller recommends the saline purgatives 
" joined with copious draughts of water." 



682 GASTRO-INTESTINAL HEMORRHAGE 



CHAPTER XII. 

GASTRO-INTESTINAL HEMORRHAGE. 

Hemorrhage from the capillaries is more frequent in infancy than at 
any other period of life, whether in consequence of the irregularity of the 
circulation and frequent congestions in the infant, or the greater delicacy 
and feebleness of the minute vessels at this age. Hemorrhage, generally 
capillary, from the gastro-intestinal mucous surface, occurs sufficiently 
often in the child, and especially in the infant, to render it a disease of 
some importance. It is more frequently the younger the individual. 

This hemorrhage occurs in three distinct pathological states : first, in 
the newborn infant from causes not fully ascertained; secondly, from a 
pathological state of the blood or the vessels in which it circulates, and 
which is often connected with purpura hemorrhagica ; thirdly, from a 
local cause. 

First Variety In 49 cases, which I have collected from different 

writers, the hemorrhage occurred in 38 under the age of six days, in o from 
six to ten days, and in 6 from ten to twenty days. Some authors cite cases 
which occurred at the age of several weeks, but hemorrhage into the in- 
testines at so late a period cannot be due to any cause operating at birth, 
and it is proper to consider such as examples of one of the other varieties. 

Passive congestion of the gastro-intestinal mucous membrane is not in- 
frequent in the newborn. Billard speaks of twenty-five cases without 
hemorrhage which he has examined. This anatomical state of the mucous 
membrane of the intestines, whether occurring as part of a general plethora 
or being simply a local affection with no hyperemia of other parts, evi- 
dently requires only a certain increase and hemorrhage inevitably results. 

The cause of the abnormal congestion of the gastro-intestinal mucous 
membrane, so common in the newborn, has been referred by writers to 
the previous health of the parents, to circumstances attending the birth, 
especially to too speedy a ligature of the cord, to irritant matters in the in- 
testines, to external violence, and to the two opposite extremes, namely, a 
plethoric and a feeble state. In my opinion, the chief cause, in many 
cases, is the tardy or incomplete establishment of the respiratory and 
circulatory functions, which gives rise to congestion in the cavities of 
the heart and in the lungs, and, consequently, in the capillaries of the 
systemic system. Evidently, this congestion is most intense in the full- 
blooded. Billard says of fifteen cases of intestinal hemorrhage which he 



GASTROINTESTINAL HEMORRHAGE. 683 

examined, most of them were remarkable for the plethoric condition of 
their bodies and the general congestion of their integuments. Some, on 
the contrary, were pale and feeble, as is common after abundant hemor- 
rhage. 

In two infants who died soon after birth, and whose bodies I subse- 
quently examined, there was apparently a plethoric state, which rendered 
a fatal result more certain, if it did not, indeed, produce it. In one of 
these, in addition to intense general congestion, meningeal apoplexy had 
occurred, although the birth of the child had been easy. 

It is not difficult to understand in what way too speedy a ligature of the 
cord may be a cause of capillary congestion and hemorrhage. At the 
moment of birth, the uterus is contracted, the placenta compressed, and, if 
the cord is now tied, more blood remains in the vessels of the infant than 
if tied a little later. A little later, in consequence of the temporary cessa- 
tion of uterine contractions, and the re-establishment of circulation in the 
infant, blood flows through the cord towards the placenta. The cord thus 
acts as a safety valve to the circulation. Any accoucheur who will take 
pains to witness the effect on the cord of the return of circulation, will ob- 
serve what I have stated. Too speedy a ligature of the cord would not, 
however, be sufficient in the majority of cases to produce that amount of 
plethora which would give rise to intestinal hemorrhage without other co- 
operating causes. 

Tardy or incomplete establishment of respiration and circulation, which 
gives rise to intestinal congestion and hemorrhage, may be due to disease 
of the heart or lungs, as atelectasis or cyanosis, to feebleness of the infant, 
or to slow and difficult birth. In a large proportion of cases, however, the 
birth is easy. Thus, three of live patients with intestinal hemorrhage, 
who were treated by M. Gendrin, were born of an easy labor, and the 
same was true of four infants observed by M. Kiwisch. 

Although gastro-intestinal hemorrhage in the newborn apparently re- 
sults in certain instances from the conditions mentioned above, which pro- 
duce congestion of the gastro-intestinal mucous surface, there are other 
cases in which the cause must be different. Dr. Silverman, of Breslau, 
has recently published the statistics of 42 cases (Jtihr. fiir Kinderk., Sept. 
1877), 23 of which were fatal. In 25 of these the blood escaped both 
from the mouth and anus, in 10 from the anus alone, and in 7 from the 
mouth alone. The hemorrhage, in a majority of the cases began in the 
second day after birth, but in 11 it began on the first day, and in all prior 
to the eighth. It is suggested that the hemorrhage, in certain instances at 
least, occurs from an ulcer in the gastro-intestinal surface, which is pro- 
duced by an embolus in the umbilical vein, or its branches, or by suspen- 
sion or incomplete establishment of the respiratory function in consequence 
of accidents of birth, atelectasis, etc. Ebstein, according to Silvermann, 
has demonstrated experimentally that the suspension of respiration in 



684 GASTRO-INTESTINAL HEMORRHAGE. 

animals produces congestion, extravasation of blood, ulceration in the sto- 
mach. From the fcetal anatomy, it is evident that an embolus occurring 
in the umbilical vein near the liver, and extending into the branches of 
the vein would be likely to cause congestion of the intestines by obstruct- 
ing the portal circulation. 

Dr. Lederer states (Zeitung fur Kinderk., Nov. 1877) that he has 
treated eight newborn infants for this disease, five of which died from the 
severe gastric and intestinal hemorrhage, accompanied also by umbilical 
hemorrhage. The age of the youngest was six hours. That of the oldest 
eleven days. They were all well-developed ; of normal conformation, and 
were nourished with breast-milk. In the three who were cured, the hemor- 
rhage was arrested in twenty -four hours, but there was for a long time a 
tendency to intestinal catarrh. Dr. Lederer admits the obscurity of the 
cause, but does not think that it was an embolism in all the cases. 

The second variety of gastro-intestinal hemorrhage often occurs as a 
sequel of other and debilitating diseases. I have known it to occur as a 
sequel of measles, smallpox, scarlet fever, and in one case of typhoid fever. 
One of these patients, when apparently the period of danger was passed, 
began to lose blood from nearly all the mucous surfaces, from the nostrils 
and gums, as well as intestines, and the case, which but for the hemor- 
rhage would doubtless have had a favorable issue, terminated fatally in 
less than a week. 

Patients with this variety of gastro-intestinal hemorrhage sometimes 
present the maculae of purpura, and commonly their aspect is pallid and 
cachectic. The following was a fatal case of hemorrhage occurring from 
the ileum, in a mild form of purpura haemorrhagica : — 

Case An infant, eight months old, of healthy parentage, nursing, with 

no previous sickness, and fleshy, vomited a small quantity of blood on the 
25th of March, 1865 ; soon after it passed a stool consisting of almost pure 
blood. On the following day five or six patches of purpura hasmorrhagica 
were observed on the arms and legs. These maculae continued till death. 
There was no more haematemesis, but the stools, which were from two to 
four daily, consisted largely of blood. Death occurred from exhaustion 
on March 31st. 

Sectio Cadaver — Head not examined ; thoracic organs healthy, but pale ; 
liver fatty; stomach, upper part of small intestines, and entire colon of 
normal appearance, unless presenting a somewiiat lighter color than the 
healthy intestine from deficiency of blood ; mucous membrane in the ileum 
to the extent of several inches, intensely injected without thickening. The 
blood had obviously escaped from this portion of the intestine, and a mod- 
erate amount of this fluid was found in the tube below the point of vascu- 
larity. This case is interesting not only on account of the development of 
purpura haemorrhagica, but the subsequent intestinal hemorrhage in a nurs- 
ing child, apparently of healthy parentage, and without previous sickness. 

In our remarks on internal convulsions, the case is related of a scrofu- 
lous infant who, to all appearance in her ordinary health, suddenly be- 



GASTRO-IXTESTIN AL HEMORRHAGE. 685 

came affected with intestinal hemorrhage in connection with external and 
internal convulsions. A point of interest in this case was the relation of 
the hemorrhage to the neurosis. In one of the three cases of intestinal 
hemorrhage described by "West, there were also convulsions. In rare in- 
stances there is an hereditary hemorrhagic diathesis to which the hemor- 
rhage is attributable. In the New York Journal of Medicine and Surgery, 
July, 1840, Prof. Swett relates the history of a hemorrhagic family. 
Seventeen out of eighteen children of this family had died of hemorrhages, 
and the survivor had had intestinal hemorrhage with epistaxis. 

In the third variety, among the local causes producing hemorrhage may 
be mentioned ulceration as in typhoid fever, or in severe intestinal in- 
flammation, the mechanical effect of solid substances, lumbrici, invagina- 
tion, obstruction to the portal circulation, polypus of the rectum. Occasion- 
ally at the post-mortem examination of young infants I have found blood 
with mucus in the duodenum and jejunum, these portions of the intestines 
being at the same time intensely congested. In one case of protracted 
entero colitis occurring in the summer season, I found many small circular 
ulcers in the colon, nearly all containing points of extravasated blood. Such 
are the principal local causes of hemorrhage from the bowels. Ordinary 
colitis may also be considered a cause, although the amount of blood 
evacuated in this disease is commonly small. 

Of the three forms of intestinal hemorrhage described above, that arising 
from local causes is most frequent, while that occurring from a purpuric 
or hemorrhagic diathesis is least frequent. In rare cases fatal intestinal 
hemorrhage may occur in the newborn, and the blood be retained in the 
intestine, or if passed it may so closely resemble the meconium that its 
true nature is not discovered. Mr. Bednar relates the following case 
(Krankheiten der Neugebornen) : " On the eleventh day after birth the 
boy's skin (then of a pale yellow color) diminished in warmth, the impulse 
of the heart became dull and prolonged, the respiratory murmur scarcely 
perceptible. The child lay almost motionless and slumbering. The day 
following the surface could scarcely be kept warm, and the little patient 
had to be aroused to suck. On the twentieth day after birth it died. The 
brain was found to be anaemic, the lungs plethoric, whilst blood was effused 
into the duodenum and stomach." 

Intestinal is more frequent than gastric hemorrhage, and the flow, ex- 
cept when produced by a local cause, is usually from the small intestines. 
The blood, unless it comes from a point near the anus, as the rectum or 
descending colon, is commonly dark, and sometimes partially decomposed, 
emitting an offensive odor. Admixture of the blood with the intestinal 
secretions prevents coagulations of the fibrin. 

Gastro-intestinal hemorrhage in itself produces few symptoms aside 
from the prostration which attends all hemorrhages. The disease w r ith 
which it is associated may give rise to many and severe symptoms. 



686 GASTRO-INTESTINAL HEMORRHAGE. 

Prognosis — The result in the first and second varieties is much more 
unfavorable than in the third. Many newborn infants affected with 
gastro-intestinal hemorrhage die, but some recover. Billard attended 
fifteen fatal cases. It is probable, however, that death in the first variety 
is often due more to some coexisting lesion, than to the intestinal hemor- 
rhage. Meningeal apoplexy, and the incomplete establishment of the 
circulatory and respiratory functions, may both operate as direct causes of 
death in this variety. 

In the second variety, also, a very guarded prognosis should be given ; 
so great a change in the circulatory system as to cause rupture of the 
capillaries, or transudation of blood in the ordinary course of the circula- 
tion, is a serious state. When this hemorrhage occurs as a sequel of the 
eruptive fevers, or in purpura hcemorrhagica, the patient is more apt to die 
than recover. 

In the third form of intestinal hemorrhage, the result depends on the 
nature of the cause, whether it is susceptible of removal. The majority 
of cases in this variety recover. 

Treatment — Billard recommends, as a means of preventing capillary 
congestion and hemorrhage in the newborn, to allow a little blood to 
escape from the umbilical cord before its ligation, if the establishment of 
respiration and circulation is difficult or incomplete. This relieves the 
hyperemia of the internal organs and facilitates the flow of blood. After 
the commencement of internal hemorrhage and the appearance of bloody 
stools, the same may be done if plethora is indicated by the florid and 
robust appearance of the infant, and the cord is not too much shrivelled. 

The treatment, both therapeutic and regimenal, of intestinal hemorrhage 
should vary according to the age and state of the infant, the profuseness 
of the hemorrhage, and the nature of the cause. Perfect quietude, in the 
recumbent position, is requisite in all severe cases. Derivation to the ex- 
tremities should be procured in the young infant, by heated dry flannel 
or flannel wrung out of hot water ; in the older infant, by the same, with 
the addition of mustard. The nursing infant should remain at the breast, 
being allowed, perhaps, in addition to the breast-milk, a little cool barley 
or gum-water. Spoon-fed infants should be given food of the blandest 
quality, in the liquid form and cool. This is the proper diet, whatever the 
age, in the commencement of the hemorrhage. If there is evidence of 
exhaustion, cool beef-tea, or essence, and alcoholic stimulants, are necessary. 
It has been advised, in -certain forms of intestinal hemorrhage, to apply 
leeches over the abdomen or around the anus. This treatment would, in 
my opinion, rarely be useful, but, on the contrary, in most cases, injurious. 
Hemorrhage from a mucous surface, when once established, will generally 
quickly relieve the local hyperemia, and leeching, unless very cautiously 
employed, would promote the prostration, in which the real danger in this 



INTUSSUSCEPTION". 687 

disease consists. On the other hand, moderate counter-irritation over the 
abdomen may be attended with real benefit as a derivative. 

The therapeutic treatment consists mainly in the use of astringents. Of 
the mineral astringents, acetate of lead and nitrate of silver have been used, 
but the liquor ferri subsulphatis is preferable to all other astringents in 
hemorrhage from the stomach and upper part of the small intestine, but 
it is believed to be decomposed in its passage through the intestine, so that 
it has less astringent or styptic effect in the lower bowel than gallic acid. 
It may be given to a child five years of age, in doses of three or four drops, 
in sweetened water or in mucilage. 

Astringent enemata are sometimes useful. M. Rilliet treated a case 
which recovered with enemata, each containing twelve grains of extract of 
rhatany, a strong decoction of the same astringent being applied externally 
to the abdomen. M. Bouchut recommends " cold water externally to the 
abdomen, internally by the mouth, or by enemata frequently repeated. 
These enemata should be composed of two or three large spoonfuls only. 
They may be rendered more active with three grains of tannin, or with 
seven grains of the extract of rhatany, or seven grains of catechu, or, lastly, 
with one grain of nitrate of silver. In this latter case, a small glass syringe 
and distilled water must be used, to avoid the premature decomposition of 
the medicine." 

In the hemorrhage occurring in purpura, or after exhausting constitu- 
tional diseases, tonics should be given in addition to astringents. In chronic 
inflammatory disease of the intestinal mucous membrane, attended by a 
vitiated secretion of the follicles, the hemorrhage may be best treated by 
turpentine. I have elsewhere related two cases of recovery by the use of 
this agent, in one of which (typhoid fever) lumbrici were expelled. Ergot, 
from the contracting influence which it exerts on the arterioles, is also use- 
ful in many cases. It is especially useful in purpura hemorrhagica. 

If the hemorrhage is due to a local cause, as lumbrici or a rectal polypus, 
the treatment obviously should consist in the removal of this cause. 



CHAPTER XIII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into another, 
has long been known as an occasional accident. Hippocrates, though de- 
barred from the study of morbid anatomy, appears to have had a pretty 
clear idea of this lesion, and he suggested a mode of treatment which has 
been employed till the present time. 



INTUSSUSCEPTION. 

Intussusception -without Symptoms. 

This is not properly a disease. It consists in a displacement without any 
other anatomical change. There is, therefore, no obstruction, inflamma- 
tion, or even congestion present, and no symptoms. This form of invagi- 
nation might ordinarily be reduced by the normal peristaltic and vermicu- 
lar movements of the intestine. 

Invagination of a portion of the small intestine into the part immediately 
below it is often observed at the post-mortem examination of young infants, 
who had presented no symptoms due to the displacement. The invaginated 
mass is usually from half an inch to two inches in length, and, as a rule, 
this accident is multiple. There may be ten or more distinct intussuscep- 
tions, at distances of a few inches from each other. The simple displace- 
ment is believed to occur ordinarily at or a short time prior to the moment 
of dissolution. It has been supposed to be most frequent in those who 
have died of cerebral or spasmodic diseases, but its occurrence is not un- 
usual in other pathological states. I have often found it at the post-mortem 
examination of infants who have had subacute or chronic entero-colitis. 
Hevin states that he has seen it at the Salpetriere over three hundred times. 
Billard has seen it especially in infants who have been subject to constipa- 
tion. Any irritant, mechanical or other, which disturbs the regular move- 
ments of the intestines, doubtless may produce it. It has been caused in 
the rabbit by irritating the anus. 

It is not improbable that simple intussusception occasionally occurs 
temporarily in children whose health remains good, when the regular 
movements of their intestines are disturbed by irritating ingesta or other 
causes. This form of displacement never takes place in the large intes- 
tine. Its usual seat is the lower part of the jejunum, and upper part of 
the ileum. As it possesses little interest as regards pathology, and none 
whatever as regards symptomatology and therapeutics, it may be ignored 
in our description of intussusception. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and danger- 
ous of human maladies, but fortunately is not very frequent. I have the 
records of fifty-two cases occurring in children, from which records the 
facts contained in this section are chiefly derived. The patients were under 
the age of twelve years. 

Previous Health In thirty-four of the fifty-two cases, the state of 

the health previously to the invagination was recorded. From the follow- 
ing table it is seen that half, or seventeen, were previously well, the re- 
maining half suffering from some disease or derangement. 



INTUSSUSCEPTION WITH SYMPTOMS. 689 

Previous Health. 



Age. Good. Disease or Derangement. 

One year or under ..... 15 8 

Over one year ...... 2 9 

17 17 

MM. Rilliet and Bartliez, whose views in reference to intussusception 
are derived from the examination of the records of twenty-five cases, state 
that the previous health is ordinarily good, and the disease is, therefore, 
primitive. Their remark, according to .the above statistics, is seen to be 
correct as regards patients under the age of one year, but incorrect for 
those over that age. 

Most of the seventeen who had previous ill-health had diarrhoea, dysen- 
tery, or constipation, or diarrhoea alternating with constipation. Of those 
otherwise affected, one had thread-worms, two obscure abdominal pains, 
one nausea and vomiting, and one whose age was four months had had 
symptoms of invagination, when ten weeks old, which soon passed off. It 
is seen that the pre-existing affections were ordinarily such as would le 
likely to accelerate the movements of the intestines and at the same time 
render them irregular. 

Causes. — The above statistics, therefore, show that intussusception is 
often preceded by disease or functional derangement of the intestines. 
The two opposite conditions, namely, constipation and the diarrhoeal 
maladies, so often precede the displacement that they must be regarded 
as common causes. Another probable cause is intestinal worms, which, 
by their mechanical action stimulate the intestines. They were present 
in three of the fifty-two patients, though two of the three seemed well till 
the occurrence of the intussusception, but the other patient had complained 
of irritation at the anus, and ascarides had been found on examination. 

The use of irritating and indigestible food is an occasional cause. Thus, 
some who have had intussusception have been in the habit of taking fruits, 
candies, and pastries freely. Such ingesta may be an immediate cause by 
their irritating effect, or a remote cause giving rise to diarrhoea, which, in 
turn, produces intussusception. 

Sex is a predisposing cause, since male patients are largely in excess. 
Of the twenty-five cases collated by Rilliet and Barthez, all but three 
were boys. In our own collection, the sex of thirty-four of the patients 
was recorded, and of these twenty-three were boys. 

In rare instances external violence is the apparent exciting cause. One 
patient received a severe contusion of the abdomen two years before death, 
and from this time continued to complain at intervals of pain in the 
bowels. One writer also mentions the case of a child nine years old who 
received a blow from a comrade at school, and from this time had alter- 
nately diarrhoea and constipation till the invagination commenced. Rilliet 
4i 



690 INTUSSUSCEPTION". 

and Barthez also relate the case of two children who were taken suddenly 
with invagination when their parents were tossing them in their arms. 

Age — Of the fifty -two cases embraced in our statistics, the ages were 
as follows : — 



3 were 3 months old. 


1 was 10 months old. 


2 " 4 


a 


cc 


1 " 11 


3 " 5 


n 


u 


1 " 12 " 


5 " 6 


<< 


n 


2 were from 1 to 2 years old. 


1 was 7 


ii 


a 


8 « " 2 " 5 " " 


1 ' " 8 


a 


<< 


8 " "5 " 12 " " 


3 were 9 


n 


n 


3 not given. 



There were, therefore, no cases under the age of three months, 23 cases 
between the ages of three and six months, or nearly one-half of the entire 
number, 8 from the age of six months to one year, and only 18 between 
the ages of one year and twelve. These statistics correspond, in the main, 
with those of Rilliet and Barthez, in whose collection of 25 cases there 
was no one under the age of four months. Leichtenstern says : " Half 
of all invaginations, according to my statistics of four hundred and seventy- 
three cases occur during the first ten years. The first year after the third 
month is remarkable for a special frequency — one-fourth of all intussus- 
ceptions." (Ziemsse?i , s Encyclop.^) 

The great liability to intussusception in infancy is due partly to the 
anatomical character of the intestine in this period of life, and partly, 
doubtless, to the fact that there are more frequent irregularities in the 
intestinal movements than in older children. In the infant the walls of 
the intestines are thin, the mucous and muscular coats and the connective 
tissue being much less developed than in those that are older ; the mesen- 
tery and meso-colon have also greater depth as compared with the same 
in other periods of Hie, except the meso-colon at the points where it passes 
over the kidneys, in which places it is very short, or even in some cases 
nearly absent. Moreover, the space occupied by the large intestine, in 
which part of the digestive tube intussusception commonly occurs, is much 
shorter relatively to the length of the intestine than in those that are 
older. In about thirty measurements, which I have made of the length 
of the large intestine and the space occupied by it, the latter was found, 
in the average, about one-third that of the former, which, of course, neces- 
sitates doubling of the intestine on itself. These peculiarities of structure 
in the infant obviously favor the occurrence of intussusception. 

Seat and Pathological Anatomy While intussusception occur- 
ring without symptoms is usually multiple, that form which occurs with 
symptoms is ordinarily single. Two exceptional cases will be presently 
related. In one recorded case there was invagination with symptoms, and 
coexisting with it another in the small intestines apparently without 
symptoms, and quickly reduced by handling. 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 691 

While intussusception without symptoms occurs in the small intestine, 
the seat of intussusception with symptoms is, with occasional exceptions, 
the colon. The colon constitutes the entire invaginated mass, or else, and 
more frequently, it forms the exterior, while the incarcerated portion con- 
sists wholly or in part of the ileum. 

Intussusception in the Small Intestines. 

Bouchut says: "M. Rilliet states, in a recent treatise, that in infancy 
the intestinal invagination is always accomplished at the expense of the 
large intestine, and that there is never invagination of the small intestine. 
This is incorrect. I have observed the small intestine invaginated in the 
adjacent inferior part. Taylor has reported a case of this kind in a child 
twenty months old, who died after an attack of acute peritonitis. M, 
Marage has seen another case in a child thirteen months old, who recov- 
ered after having voided the invaginated portion furnished with two of 
those diverticula so frequent in the small intestine of the foetus." 

But, from all that appears, the case reported by M. Marage may have 
been, and probably was, an example of the common form of intussuscep- 
tion, namely, of the ileum into the colon. In Mr. Taylor's case the in- 
vagination was really of the ileum into the colon, although a small portion 
of the ileum next to the valve had not been inverted, so that it constituted 
a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal 
intussusception may occur in the small intestines. Probably the displace- 
ment is at first of the simple variety, but, continuing and increasing in 
extent, its return becomes impossible. The positive statement of so great 
an authority as M. Rilliet, that intussusception with symptoms does not 
occur in the small intestines, justifies the publication of the following 
cases, which establish the fact that there are instances, though not fre- 
quent, in which the displacement does have this location : — 

Case I — Male. This patient's health had been uniformly good, and 
nothing unusual was observed in his condition till the age of four and a 
half months, when he became restless as if in almost constant pain, with 
occasional exacerbations. Castor oil was prescribed, which operated freely, 
and then the following mixture : — 

I£. Magnes. calcinat., Qj ; 

Tinct. opii cainpliorat., ^ij ; 
Tinct. asafoet., 3ss ; 
Aq. anisi, §j. Misce. 
Dose, ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given in doses 
of two drops. After two or three days, another set of symptoms arose, 
those characteristic of pneumonitis, namely, hurried respiration, accel- 
erated pulse, short, suppressed cough, and expiratory moan. He was 
treated with the oiled silk jacket, and mild counter-irritation, and took an 



692 



INTUSSUSCEPTION. 



expectorant mixture containing carbonate of ammonia. In a few days the 
pnlmonarv disease was evidently subsiding, but the pain in the abdomen, 
with occasional exacerbations, continued. His countenance was pallid, 
and bore an expression of suffering. There was no distension or tender- 
ness of abdomen, and no abdominal tumor. He took little nutriment, and 
seldom vomited-. In the last part of his sickness the dejections were scanty, 
and the last three days his stools consisted mainly of mucus and a little 
blood. The pain seemed to be growing less, when he was seized with con- 
vulsions, and died the same day, precisely two weeks from the commence- 
ment of his sickness. 

Sectio Cadaver Head not examined ; body slightly emaciated ; mucous 

membrane of trachea and bronchial tubes vascular ; posterior portion of 
the lower lobe of each lung solid, of greater specific gravity than water, 
and allowing only partial inflation ; it was in the second stage of pneu- 
monitis. Stomach, duodenum, jejunum, healthy. In the upper part of 
the ileum was an intussusception two-thirds of an inch long, presenting no 
trace of inflammation, either within or around it, and its vascularity, when 
it was examined externally, did not seem notably increased. Above the 
intussusception the intestine was empty ; below it, and chiefly in the small 
intestine, was a dark-colored substance evidently blood, and giving in a 
few hours the offensive odor of decaying animal matter. There was a pas- 
sage through the intussusception, at least two or three lines in diameter, 
as shown by a probe. The intussusception sustained the weight of sixteen 
inches of the intestine, and it would apparently have sustained consider- 
ably more. The remaining organs were healthy. 

Case II F. 8., a female infant, four months old, was treated at the 

New York Infant Asylum in June and July, 1865, for entero-colitis, the 

Fig. 25. 




usual epidemic of the summer season. The following records show the 
state of the bowels immediately before her death : — 

June 29th. Has five or six stools daily. 30th. Two stools in twenty- 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 693 

four hours. July 1st. Had two stools since the last record; no vomiting*. 
3d. Four stools in last twenty-four hours. 4th. The diarrhoea continues 
as before ; the stools about four daily. On the 6th of July she died. 

Her pulse during the time in which these records were taken generally 
numbered about 128 per minute. She was much emaciated, and the day 
before death she frequently struck her head with the hand. The medi- 
cines employed were mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; some serous effusion over the 
convolutions of the brain, under the arachnoid; occipital bone depressed; 
commencing at a point about two feet below the stomach were four intus- 
susceptions two or three inches from each other. The invaginated masses 
were from one to one and a half inch in length, and three of them were 
found to be very vascular in their interior. Above, between, and imme- 
diately below the intussusceptions the intestine w r as healthy. One of the 
invaginations was tested by weight, and was found to sustain one and a 
half foot of intestine, and would have sustained more. Water poured 
above these intussusceptions escaped through them very slowly ; no fib- 
rinous exudation; descending colon vascular and thickened, and solitary 
glands enlarged. 

The irreducible character of the intussusceptions in the above cases was 
shown by the fact that they sustained weights which doubtless produced 
greater traction than that exerted by the intestine in its normal action. 
That the displacement existed prior to the moment of death was shown by 
the symptoms in one of the cases and by the anatomical changes in both. 
In one the capillaries of the incarcerated mass were ruptured during the 
last days of life, so as to produce sanguineous stools ; while in the other 
there was intense congestion of the invaginated mucous membrane, while 
that portion of this membrane which was adjacent but not engaged was 
healthy. 

In both patients the symptoms were less severe than in ordinary cases, 
and they came on more gradually, for the invaginated intestine was not 
completely closed, so that it allowed the passage of fecal matter in one till 
the close of life, and in the other till near its close. At both of the 
autopsies water poured into the intestines above the invaginations passed 
slowly through them. 

Intussusception in the small intestines in the infant, commencing as the 
simple form, may become irreducible, and yet remaining pervious may 
continue for weeks without giving rise to severe or dangerous symptoms. 
The following case was an example of this : — 

Case — Male child, died at the age of nineteen months, the last eleven 
of which he was under observation. The mother states that he had never 
been well since the age of one month, and that there had been little varia- 
tion in the symptoms of his disease. During the period in which he was 
under observation, he was ordinarily fretful, and frequently seemed to be 
in considerable pain. His stomach through this whole time was so irritable, 
that he rarely took more than three or four spoonfuls of nutriment without 
vomiting. There was usually more or less diarrhoea, but no tenderness or 
distension of abdomen. He became slowly but gradually more emaciated, 



694: INTUSSUSCEPTION. 

and finally died in a state of extreme emaciation and exhaustion. He had 
no convulsions, and was conscious to the last. 

Sectio Cadaver — Brain not examined ; lungs healthy, except a circum- 
scribed portion, which was inflamed at the summit of the right lung; liver 
small and almost destitute of oily matter, as shown by the microscope. 
In the jejunum, about two feet below the stomach, was an intussuscep- 
tion two inches long, the intestine forming which seemed to have under- 
gone no structural change. Above the intussusception the intestine was 
of small calibre, and entirely empty and pale ; below the intussusception 
the intestine was somewhat larger than above, but it seemed quite healthy. 
The invagination was sufficiently pervious to allow water to pass through 
it, and it readily sustained the weight of two feet of intestine. From 
eight to ten inches below this intussusception there was another, which 
was immediately drawn out the moment the intestine was disturbed. The 
other abdominal viscera were healthy. 

There is uncertainty as to the duration of intussusception in the above 
case, but the symptoms indicated that it existed a considerable time prior 
to death. There was no strangulation, nor indeed any appreciable ana- 
tomical alteration in the coats of the intestine, but the fact that the in- 
vaginated mass sustained two feet of intestine, and required considerable 
traction for its reduction, shows that it was not a case of simple displace- 
ment occurring at the moment of death and without symptoms, but was 
an example of the variety with symptoms. 



Intussusception in Large Intestines. 

In most cases of intussusception occurring in infancy and childhood, 
the ileum is invaginated in the colon, or the first part of the colon is in- 
vaginated in the part succeeding it. Intussusception not unfrequently 
begins in the prolapse of the ileum through the ileo-caecal valve, in the 
same way that prolapse of the rectum occurs through the sphincter ani. 
If death take place early, only a small portion of the ileum may have 
passed the valve. If the case is protracted, the tenesmus brings down 
more and more of the ileum, with its accompanying mesentery. The con- 
striction of the valve, which acts as a ligature, soon prevents the further 
descent of the ileum ; and, the tenesmus continuing, the next step in the 
displacement is the inversion of the caput coli, which is drawn into the 
colon by the descending mass, and, unless the case terminate by sloughing 
or death, the ascending and transverse portions of the colon are succes- 
sively invaginated. The records show that intussusception occurs as above 
stated in a large proportion of cases. In one case, among those which I 
have collated the intussusception began a few inches above the valve, so 
that the ileum constituted a small portion of the exterior of the mass. 
Occasionally the csecum is the part primarily inverted and invaginated, 
and, descending along the colon, it draws after it the ileum, which sustains 
its natural relation to the ileo-cascal valve. When this occurs the caecum 



INTUSSUSCEPTION IN LARGE INTESTINES. 695 

is found at the lower end of the mass, and two orifices are observed, one 
leading through the valve, and the other into the appendix vermiformis. 
These two forms of invagination — that in which the ileum, passing through 
the ileo-cascal valve, successively inverts and draws after it the caput coli 
and the divisions of the colon ; and that in which the caput coli is primarily 
invaginated, and descending along the large intestines, inverts the latter, 
and draws after it the ileum — constitute the vast majority of cases of this 
disease in the first years of life. 

I have notes of 45 fatal cases occurring under the age of twelve years, 
in Avhich the portion of intestine first displaced is recorded. In four of 
these the displacement was entirely in the small intestine, involving in no 
way the colon ; in 38 cases it commenced either by prolapse of the ileum 
through the ileo-ca?cal valve, or by inversion of the caecum into the ascend- 
ing colon, there being perhaps not much difference in the relative frequency 
of these two modes ; in one case the invagination was confined to a seo-- 
ment of the transverse colon, in another to a segment of the descending 
colon, and in the remaining case to the lower part of the descending colon 
and the upper part of the rectum. In three instances the invaginated mass 
itself became invaginated, producing an intussusception of great thickness 
and necessarily fatal. 

As we have seen in regard to intussusception in the small intestines, so 
that occurring in the large intestine may be attended by so little constric- 
tion of the incarcerated portion that it remains pervious, though with 
diminished calibre. In such a case life may be protracted for weeks or 
even months, without reduction of the displacement or any material 
change in it, the passage of fecal matter being sufficiently free for the 
maintenance of life. Death finally occurs in a state of exhaustion. Thus in 
one instance a child, four months old, lived six weeks after the symptoms of 
invagination commenced, and seventeen days "with a portion of the bowel 
protruding from the anus." It was found at the post-mortem examination 
that part of the ileum had descended through the entire colon, and had 
remained pervious. In a case related by Dr. Worthington in the Amer. 
Jour, of Med. Set. for January, 1849, there were symptoms of intussus- 
ception for seven months before death, and during the last six weeks of 
life, the invaginated intestine protruded frequently from the anus, and was 
replaced by the mother. In this case " the caecum was inverted, and de- 
scended through the colon to the lower portion of the rectum, carrying 
with it the ileum and the entire colon, except the last ten or twelve 
inches." In another case the symptoms indicated a continuance of the 
disease for three, if not eight, months. But such cases are exceptional. 
Ordinarily as the intestine becomes invaginated, its mesentery or meso- 
colon is also invaginated, and its veins compressed. The pathological 
state of the incarcerated mass soon becomes that of intense congestion. 
In infants, usually in a few hours, so great is the distension of the capil- 



696 INTUSSUSCEPTION. 

laries that they give way, blood escapes into the intestine, and passes from 
the bowels in scanty motions. On examining the invaginated intestine 
after death, if gangrene has not occurred, it is found of a uniform intense 
red color, sometimes resembling to the naked eye a long and firm clot of 
blood. In those who die early there are no traces of inflammation, but in 
more protracted cases the attrition between the serous surfaces excites 
local peritonitis. But in none of the fifty-two cases which I have collated 
in which post-mortem examinations were made, did the inflammation ex- 
tend more than a few lines beyond the invagination. Usually the intestine 
forming the exterior of the invaginated mass is much drawn together or 
puckered. In one case treated by myself, the entire large intestine which 
formed the exterior of the mass was compressed within a space of six 
inches or less, since about twelve inches of the ileum, doubled on itself, 
lay within the entire colon and protruded from the anus, the only part of 
the large intestine which was inverted being the caput coli. In one case 
six or seven inches of the ileum, which formed a portion of the exterior 
of the mass, were compressed within the space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes more 
and more distended till the close of life ; but in cases of much vomiting 
the distension is moderate. This fulness is due to gas and fecal accumu- 
lation above the invagination. The portion of intestine below the dis- 
placement is ordinarily empty, except that in the infant it commonly 
contains mucus, mixed with more or less blood, which has escaped from 
the capillaries of the strangulated mass. 

There are few anatomical changes in this disease, which do not arise 
directly from the intussusception, and are, therefore, located either within 
the mass or in its immediate vicinity. In those who recover by the pro- 
cess of sloughing, the cicatricial contraction may give rise to symptoms 
and lesions of greater or less gravity. Thus the late Sir James Y. Simp- 
son examined a child aged 9 years, who recovered with loss of ten inches 
of intestine, and at the meeting of the Medical Society, before which the 
specimen was presented, remarked that there was unusual distension of 
the cutaneous veins of the patient, due probably to such compression of the 
ascending vena cava by the cicatrix, that the venous circulation was ob- 
structed. {Trans. Medico-Chir. Soc, Edin.) In the London Lancet for 
1854, Mr. Charles King relates the case of a child aged 6 years, who, on 
the eleventh day of the disease, voided the caecum and a part of the colon. 
Two days subsequently pulsation ceased in the left leg, and all that part 
below the patella became gangrenous. The patient gradually recovered 
with loss of the leg. The cause of this unfortunate sequela was doubtless 
compression from the cicatricial contraction of the artery which supplied 
the leg, and probably the formation of a thrombus. In the Lond. Med. 
and Phys. Jour, for December 18th, 1828, Dr. F. Bush relates a case in 
which he was enabled to observe the extent and appearance of the cica- 



SYMPTOMS. 697 

trix. The patient, aged twelve years, discharged from the bowels fifteen 
to eighteen inches of the ileum on the eighth day of the intussusception, 
after which convalescence was rapid. Fourteen weeks later the child died 
from typhus fever, and at the autopsy " traces of the diseased bowels were 
visible by a contraction and puckering where the slough had taken place, 
and the parts united." But fortunately in most instances when the in- 
testine sloughs and the child survives, no serious or permanent injury 
results from the cicatrization. The cicatrix stretches little by little, and 
accommodates itself to the surrounding parts. 

■ Symptoms The symptoms vary according to the age of the patient 

and the degree of strangulation. Pain in the abdomen, usually parox- 
ysmal, is among the first, and is one of the most conspicuous symptoms. 
It is often severe, resembling the pain of hernia, and abating only with the 
failing strength of the child. After the first few days, if inflammation 
arises, the pain is continuous, though more severe in paroxysm. At first 
pressure upon the abdomen is tolerated, but afterwards there is tenderness. 
This is due to the inflammation, which occurs in and around the invagi- 
nated mass, and it is, therefore, confined to the part of the abdomen in 
which the tumor lies. At this point also the abdomen is more full than 
elsewhere, and not unfrequently the physician can feel the invaginated 
mass and detect its exact location, and approximately its extent. Some- 
times, at an early period as well as late, cerebral symptoms occur, as in a 
case related by Dr. Coggswell in the London Lancet for July, 1853, which 
terminated in convulsions and death on the second day. Convulsions are, 
however, comparatively rare, and the mind is generally clear till the last 
moment. In infants the countenance, in the intervals of pain, in the first 
stages of the complaint, is often placid and not indicative of any serious 
disease, but in older patients constant and severe local symptoms, referable 
to the intussusception, commence early. At an advanced period, what- 
ever the age, the countenance ' becomes anxious and haggard, the eyes 
hollow or sunken, the body loses its plumpness, and, if the case is pro- 
tracted, becomes emaciated. 

Vomiting is rarely absent; in thirty-nine out of forty-seven cases it is 
stated to have been present ; in seven cases there is no record of this 
symptom, while it is recorded absent in only one case ; but in this case, 
the records of which are very meagre, death occurred on the second day. 
The vomiting becomes stercoraceous in a few days, and it ordinarily con- 
tinues with greater or less frequency till the period of collapse. It relieves 
partially the distension. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather 
than hunger. 

There is commonly one natural evacuation from the bowels after the 



INTUSSUSCEPTION. 

intussusception commences, and then obstinate constipation succeeds. 
This evacuation consists of the excrementitious matter below the invagi- 
nation. In children under the age of one year, scanty motions of blood 
mixed with mucus begin to occur in a few hours. In twenty-seven 
children under this age I find that twenty-four had such evacuations, 
occurring in most of them several times in the course of the day; in two 
of the twenty-seven there is no record of this symptom, but in the remain- 
ing case it is stated to have been absent. Scanty evacuations of blood 
unmixed with fecal matter have been considered pathognomonic of intus- 
susception in the infant, and we see the ground for such belief; but in 
exceptional instances the invaginated mass is partly pervious, and although 
the dejections may contain blood they are also excrementitious. In our 
collection of cases are three examples of this in infants under the age of 
one year. One has already been referred to. In this case there was the 
rare anomaly of so large an opening through the ileo-cascal valve, as to 
allow not only prolapse and descent of the ileum through the entire colon, 
so as to protrude six inches from the anus, but also fecal passages through 
it daily. 

In children above the age of one year, the capillaries of the invaginated 
intestine are not so frequently ruptured as under this age, and sanguineous 
evacuations are therefore less common. I have records of nineteen cases 
between the ages of one year and twelve, in only six of which it is stated 
that there were bloody motions, and in these the blood was not passed 
frequently, nor even in some cases daily, as in infants, nor in so pure a 
state, unless in two cases, the records of which are not explicit on this 
point. Two of these six patients passed moderate bloody evacuations 
after protracted periods of constipation, one had fecal discharges with the 
blood through the entire sickness, and in one blood was passed at first, 
but finally the stools were entirely fecal. 

In those above the age of one year, there was for the most part obsti- 
nate constipation, no dejections, whether bloody or fecal, occurring for 
several days, but there were a few exceptions. In three cases the bowels 
were relaxed. The ileum, in these three, had descended through the 
entire colon, or the larger part of the colon, and being pervious, the feces 
escaped from the anus without detention in the large intestine, or with 
detention only in its lower portions, and were therefore liquid. 

Tenesmus is another symptom. It is not always present, but in a large 
proportion of cases, even when the invagination is in the upper part of the 
large intestine, it is a frequent and distressing symptom. It often does 
not commence till there is a considerable amount of displacement, and it 
ceases when the strength is much reduced. 

The temperature of the surface is normal in the commencement of 
intussusception ; but finally, as febrile reaction comes on symptomatic of 



DIAGNOSIS — DURATION. 699 

the inflammation, it rises and continues above the healthy standard till 
the intestine sloughs, or till the stage of collapse occurs which ushers in 
death. The pulse, especially in the infant, is tranquil at first, but, what- 
ever the age, it soon becomes accelerated from the paroxysms of pain, and 
subsequently from the inflammation which occurs in the invaginated 
mass. There is no disturbance of respiration, except that it is somewhat 
hurried from the fever, and from the pain felt in advanced cases on full 
inspiration. 

It will be seen that the symptoms vary in certain particulars, under the 
age of one year, from those occurring over that age, but differences in the 
symptoms depend more on the degree of invagination and constriction, 
than on the age and exact location of the disease. 

Diagnosis The diagnosis of intussusception is not, in general, diffi- 
cult, except at its commencement. When the inversion has reached that 
degree at which obstruction occurs, the symptoms are, in most cases, such 
that the disease can be readily diagnosticated. In the cases whose records 
I have collated a correct diagnosis was, with few exceptions, made, and at 
an early period. In the infant, the disease for which intussusception is 
most frequently mistaken is dysentery, on account of the tenesmus and the 
muco-sanguineous stools. In certain of the reported cases this mistake 
was not rectified until it was ascertained that purgatives produced no fecal 
evacuations. 

The symptoms which are commonly present, and which indicate the na- 
ture of the disease, are obstinate constipation, vomiting, paroxysmal pain 
referred to the seat of the disease, and tenesmus. In the infant, also, scanty 
evacuations from the bowels of mucus and blood, or of pure blood, is, as we 
have seen, an important diagnostic sign. It should be borne in mind, 
however, that in exceptional cases the displaced bowel may remain per- 
vious, and the usual symptoms which possess diagnostic value therefore 
be absent. There may be no vomiting or tenesmus, and there may even 
be diarrhoea in place of constipation, as in the cases related above. As an 
aid to diagnosis, it should be stated that whatever the age of the child af- 
fected with intussusception, clysters are often administered with difficulty. 
and are quickly and forcibly returned, on account of the resistance op- 
posed by the invaginated mass. \Ye have stated above that the seat and 
even extent of displacement can be ascertained in a large proportion of 
cases by digital examination of the abdominal walls. The tumor can be 
felt hard, elongated, and tender on pressure, so that the diagnosis is clear. 
If the invagination be in the lower part of the large intestine, it can some- 
times be discovered by an examination per rectum. 

Duration — In the following table, the duration of the intussusception 
in forty-nine cases is given, as nearly as it can be ascertained from the 
records : — 



6 


u 


" 2d 


14 


u 


" 3d 


2 


<< 


" 4th 


5 


<< 


" 5th 


2 


it 


" 6th 


2 


(.( 


" 7th 



700 INTUSSUSCEPTION". 

2 died the 1st day. 1 died the 8th day. 

1 " " 10th " 
1 u " 14th " 
1 lived nearly a week. 
1 " 6 weeks. 
3, time of death not given. 
7 recovered. 

1 lived over a week. 

In two of the three cases in which the duration is not stated, the patients 
lived much longer than the usual period. One of these two, a girl of six 
years, having eaten raw carrots, was seized with pain in the abdomen, which 
lasted eight months, when she died. During the last three months she 
passed mucus and blood. In this case the caecum had descended to the 
anus, drawing with it the ileum, which remained pervious. The symptoms 
indicated the continuance of the invagination for three months if not eight. 
The other patient was a boy, aged 3 years and 4 months, who complained of 
pain in the abdomen for many months, and occasionally vomited. During 
the last six weeks of his life, all the phenomena of invagination were present. 
In this case also, the inverted caput coli had descended along the entire 
length of the colon, and it lay at the autopsy in the rectum. 

In West's Treatise on Diseases of Children (fifth edition, 1866, page 504), 
it is stated that death in this complaint always occurs within a week. The 
above statistics, however, show that there are exceptions to this statement, 
although a large majority do die within the first seven days. In thirty- 
three of the cases embraced in my statistics death occurred within the first 
week, and in no fatal case in which strangulation was complete was life 
prolonged beyond the eighth day. In these cases of complete strangula- 
tion the average duration was 3.7 days, and the largest number of deaths 
occurred on the third day. Death on the first day is rare, but it occurred 
in two instances. When so early it is often, if not generally, in convul- 
sions and coma. 

Prognosis Intussusception is in its nature so grave an accident that 

the physician called to a case should always explain its gravity to the 
friends. But, while death is a common result, there are three different 
modes of termination in which life is preserved. First, the reduction of 
the incarcerated intestine, with immediate relief. There can be no doubt 
that it is possible for intussusception, when recent, to be reduced by the 
unaided action of the bowels, in the same ^vay as the common, simple in- 
tussusception in the jejunum and ileum, or as hernia is reduced, through 
the vermicular action of the intestines. For sometimes, as in Dr. Coggs- 
well's case (Lond. Lancet, July, 1853), the patients at some previous time 
have experienced the same symptoms as those which accompanied the at- 
tack, and which subsiding, they remained for a time in perfect health. This 
termination is probably rare, if the symptoms are sufficiently marked to 
necessitate treatment. Again, the intussusception may be cured by early 



PROGNOSIS. 701 

and well-applied treatment. The physician may succeed in reducing the 
displaced intestine, even if the intussusception is in the upper part of the 
colon. 

A second mode of favorable termination is alluded to by certain foreign 
writers. The intussusception continues for a considerable period with the 
characteristic symptoms, and then, as Bouchut expresses it, " the vomit- 
ings gradually cease, the intestinal hemorrhage disappears, the strength 
returns, and the health becomes restored without the expulsion of frag- 
ments of the intestine.'' What changes the displaced intestine undergoes 
in these protracted cases, which gradually recover without sloughing, have 
not been clearly ascertained, although they have been the subject of con- 
jecture. According to Rilliet, a large proportion of favorable cases ter- 
minate in this manner. It does not appear, however, from the statistics 
which I have collected, that this is the common mode of recovery. The 
clinical history of intussusception establishes the fact that in a large 
majority of protracted cases there is either death or the third mode of 
favorable termination, namely, by sloughing. 

But we cannot reasonably expect recovery in young children through 
sloughing and the expulsion of the intestine ; since few have the requisite 
strength for so tedious and exhaustive a process. The youngest child that 
recovered in this way, so far as I have been able to ascertain, was an 
infant thirteen months old, whose case was reported by M. Marage. With 
the exception of this case, the youngest was a boy, aged five years. The 
older the child, the greater, of course, the power of endurance, and the 
better the prospect of recovery. Of the fifty two cases whose records I 
have collated, seven recovered by the sloughing and expulsion of the mass. 
These children were of the ages of five, six, six, nine, eleven, twelve, and 
twelve years. The separation of the invaginated mass occurred in six of 
of these between the sixth and twelfth days, with an average of nine and 
a half days, the time not being given in one case. If, then, the patient 
can be carried through the first week without too much exhaustion, we 
may each day look for the discharge of the slough, the reopening of the 
bowels, and ultimate recovery. 

But in those cases in which the intussusception remains open, so as to 
allow the passage of fecal matter, recovery is improbable unless the dis 
placement is diagnosticated early and properly treated. If the intussuscep- 
tion continues, it becomes greater and greater from the absence of strangu- 
lation. Without inflammation and with little or no congestion of the 
displaced portion, and without the severe symptoms which occur in ordi- 
nary cases, the patient wastes away, having irregular evacuations and 
more or less abdominal pain, and finally dies in a state of emaciation and 
weakness. In the early stage of this form of displacement it is not im- 
probable that injections or inflation, employed with sufficient force, will 
give relief, but, if the early period passes without such treatment, cure is 



702 INTUSSUSCEPTION. 

impossible by the ordinary methods. It is in such instances especially, to 
wit, those in which the displacement occurs without strangulation or in- 
flammation, and in which fecal matter passes through the displaced mass 
more or less freely, that laparotomy is justifiable, and is likely to give 
relief, when injections and inflation have been employed in vain. Jona- 
than Hutchinson's successful performance of this operation in a child of 
two years, who had this kind of displacement, is known to most readers. 
(See London Lancet, November 22, 1873.) 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively 
easy. An interesting case of this kind was observed and treated by Drs. 
O'Dwyer, Reid, and myself, in the New York Foundling Asylum, in 1875. 
The child was a female, aged two years, and had had previous good health. 
The invaginated mass protruded like a prolapse, about four inches outside 
of the anus. It was cold, considerable hemorrhage had occurred from it, 
and the infant seemed in collapse. When the mass was returned so far 
as it could be carried within the pelvis, by the index finger, the lower end 
of it could still be felt like an os uteri. It protruded four or five times 
within twenty-four hours, but, by replacement so far as possible with the 
fingers, and the use of simple water injections, it was finally permanently 
reduced, and, with the use of stimulants, she soon fully recovered. 

Modes of Death This is different in different cases. It sometimes 

occurs from collapse. At a meeting of the New York Pathological So- 
ciety, held December 10, 1873, I presented a specimen, showing intus- 
susception occurring about one foot above the ileo-crecal valve, in an 
infant aged thirteen months. On the day before its death, its previous 
health having been good, it seemed ill, and vomited once or twice, but did 
not appear to be in pain. It had two evacuations from the bowels, of the 
usual appearance, in the latter part of the day. On the following morn- 
ing it was unexpectedly in collapse, and died within about twenty-four 
hours from the commencement of the sickness. At the post-mortem ex- 
amination the head was not opened, and all the organs of the trunk were 
found normal except the intussusception. The mass involved in the dis- 
placement measured two and a half inches in length, and was slightly 
crescentic. The mucous membrane above and below it had the normal 
appearance, as did that of the external or incarcerating portion of the 
mass, while that of the incarcerated part was deeply injected. Water 
poured into the intestine above the invagination was wholly arrested by it. 
{New York Med. Bee, April 1,1874.) But in the majority of instances 
death occurs from asthenia, which comes on gradually, but increases rap- 
idly in consequence of the pain, vomiting, and imperfect nutrition. Chil- 
dren dying in this way may have convulsive movements more or less 
marked, but the prevailing characteristic as death approaches is extreme 
exhaustion. In exceptional instances the life of the sufferer is cut short 



TREATMENT. 703 

by convulsions before the stage of exhaustion is reached. Thus a child 
aged three years, whose case was reported by Dr. Isaac Thomas, in the 
Amer. Med. Recorder, in 1823, and another, aged two years, whose case 
was reported by Dr. Coggswell, in the London Lancet, July, 1858, died in 
convulsions on the second day. 

Treatment It is unfortunate, in cases of intussusception, that the 

time in which treatment can be of most service is apt to pass by before 
the true condition of the intestine is detected. Invagination being com- 
paratively rare, the patient is generally on the first day treated for colic 
or dysentery or some other common affection of the bowels; and it is often 
not till the second day, when the intestine has become incarcerated, that 
the physician accurately diagnosticates the disease. The purgative medi- 
cines often given in the commencement injure the patient. In fact, both 
reason and experience teach us the impropriety of purgatives in this com- 
plaint. Cathartic remedies act as a vis a tergo, and may cause still further 
descent of the inverted intestine. Yet such powerful agents of this class 
as quicksilver have been employed. It was administered in two doses of 
one ounce each in one of the cases embraced in my statistics, but none of 
the mineral passed the bowels. At the post-mortem examination a con- 
siderable part of it was found in small globules, coated with a black layer 
consisting of the sulphuret or black oxide of mercury, in the intestine 
above the intussusception. It need not be added that the case was speedily 
fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. This pressure may be applied 
either by liquid injections into the rectum or by inflation of the lower 
intestine by air or gas. 

Injections should be made with lukewarm water, for cold or hot water 
may cause contraction of the muscular fibres of the intestine, and increase 
the constriction. The child should be placed in bed, or in the nurse's lap, 
with the nates elevated 45°. With the common India-rubber, or better the 
fountain-syringe, and the aid of an assistant, the liquid should be gently 
thrown into the rectum until the abdomen is somewhat distended. By 
carrying the fingers, firmly but gently applied upon the abdominal walls, 
along the direction of the colon, the liquid is made to press against the 
lower end of the intussusception. The same gentleness and perseverance 
is required in kneading and pressing the abdominal walls as in the treat- 
ment of hernia, by taxis. If the invagination is in the descending colon, 
probably only a small quantity of the liquid can be injected, and it may be 
forcibly returned, but by repeating the injections, a sufficient quantity can 
ordinarily be introduced to obtain the full effect of the mode of treatment. 
There is also sometimes an increased irritability of the rectum, even when 
the intussusception is at the other extremity of the large intestine, so that 
tenesmus and expulsive efforts follow the introduction of the instiument. 



704 INTUSSUSCEPTION. 

The assistant can aid in overcoming this by pressing the soft parts of the 
nates around the instrument. 

If the injection fail to reduce the displacement, it may be repeated after 
allowing the patient to rest for awhile. In the New York Medical Journal 
for May, 1875, is the history of an interesting case, which was treated by 
Drs. Church and Warren, of this city, and is reported by the latter. The 
infant was seven months old and had the usual symptoms, such as frequent 
paroxysmal pain in abdomen, vomiting, tenesmus, scanty muco-sanguineous 
stools. On the third day injections were twice employed without result, 
but on the fourth day an injection of ten or twelve ounces reduced the dis- 
placement, and the infant recovered. In a second case treated by Dr. 
Warren the age was nine months, and a tumor appeared a little above 
the umbilicus a few hours after the commencement of the symptoms. The 
following is Dr. Warren's account of this interesting case which will give 
a clear idea of the proper mode of treatment. 

" The patient was looking very pale and prostrated, the pulse was quick 
and feeble, and the skin cold. I at once determined to use fluid injections, 
and, with the little patient placed in a semi-prone position in his mother's 
lap, with an ordinary Davidson's syringe I commenced injecting tepid soap 
and water, but after perhaps a gill had been thrown into the rectum it was 
almost immediately rejected, very highly colored with blood, and mixed 
with it a very small quantity of mucus and fecal matter; the latter, by 
the w T ay, not hardened, but of the consistency of soft putty. In a second 
attempt the fluid was retained longer, but was after a little while dis- 
charged, with more blood and mucus, but with much less tenesmus and 
pain. 

"When, soon after, I made my third attempt, the child's chest was rested 
upon the side of its mother's lap, with the lower extremities elevated by an 
assistant, so that the position was at an angle of about 45°, anus upward. 
This time I injected the fluid very slowly, in order to avoid, if possible, 
the irritation caused generally by the frequent emptying and refilling of 
the syringe (which, by the way, is a very serious hindrance to the success- 
ful use of this syringe, and which renders it much inferior to the fountain 
or hydrostatic). In this manner I succeeded in injecting, as I estimated 
at the time, perhaps ten or twelve ounces, and during the operation the 
child gradually became more quiet, and had, when I ceased, fallen asleep. 
Then, with the direction that occasional doses of tinct. opii camph. should 
be administered during the night, to control, if possible, the peristaltic 
action of the intestines, I left him. 

" On the following morning, to my surprise, I found the child sleeping 
quietly and naturally, and I was informed that at about 5 A. M. (six hours 
after my visit) he had a movement of the bowels, which was saved for my 
inspection, and consisted simply of the enema, slightly colored with fecal 
matter. From that time he seemed to be entirely free'from pain, and six 



TREATMENT. 705 

or seven hours later had a natural passage, after which recovery progressed 
rapidly, and in a few days he was discharged well." 

The following case is interesting as showing success from the use of in- 
jections after the lapse of two days, in a severe case, which had resisted 
treatment on the first day. The good result was apparently in great part 
due to the manipulation which was made so as to press the Avater against 
the course which intussusceptions are known to take. 

On September 10, 1876, I visited, with Dr. Gillette, a nursing infant, 
aged nine months, whose history was as follows : It was habitually consti- 
pated, but it continued in its usual health till September 8, on which day 
it was carried by its nurse to one of the city parks. After its return it 
began to be fretful ; it vomited, and seemed to be in pain. It continued 
to vomit frecpiently, especially after nursing, or taking drinks, and in the 
ensuing night passed two scanty stools of mucns and blood without fecal 
matter. In the morning of September 9, Dr. G. was summoned, who 
found the pulse 180, and temperature 102°, and the matter vomited 
greenish like bile. In the evening the temperature was 102 j°. Dr. G. 
diagnosticated intussusception, and employed injections of water, but they 
were returned without bringing fecal matter, and without apparent result. 
He also administered opiates by the mouth. 

September 10, temperature 102 J° ; features pallid, and beginning to have 
a pinched or sunken appearance, and they indicate much suffering ; no 
nutriment is apparently retained on account of the frequent vomiting, and 
the bowels are obstinately constipated. As the symptoms indicated rapid 
sinking and collapse, consultation was called at 4: P. M. It was impossi- 
ble to determine certainly, through the abdominal walls, on account of the 
distension, whether there was any tumor, but it was my opinion, and the 
opinion of one of the other physicians, that a tumor, hard and inelastic, 
could be felt nearly in the median line, between the umbilicus and the 
symphysis pubis. At about 5 P. M. the shoulders of the little patient 
were lowered, and the nates elevated, so that the trunk formed an angle of 
perhaps forty-five degrees with the horizontal, and a large quantity of tepid 
water was gently passed into the intestine through Davidson's syringe, 
with the vaginal nozzle attached. It was impossible to estimate the quan- 
tity retained, since a considerable part of it escaped, although the anus 
was firmly pressed around the instrument. 

When the abdomen was distended as fully as seemed justifiable, the 
nates being still elevated, and the liquid retained, so far as possible, by 
firm pressure upon the anus, the abdomen was firmly and deeply kneaded 
by the hand, the movements being made chiefly from the right lumbar 
towards the right inguinal, and from the right inguinal towards the 
hypogastric region. The kneading was continued perhaps eight to ten 
minutes, and the water, which contained no perceptible amount of fecal 
matter, blood, or mucus, was allowed to escape. 
45 



706 INTUSSUSCEPTION. 

After this operation the child became quiet, slept, and the vomiting 
ceased. At our next visit at 7 P. M., although the severe symptoms had 
in great part abated, and the countenance had lost that pinched and suf- 
fering aspect which was so prominent before, it was deemed best, in con- 
sultation, to repeat the injection, and this time through a rectal tube, 
which was introduced further than the nozzle employed at the preceding 
visit. The body was placed in the same position as before, and the ab- 
domen kneaded in the same manner. The water, when allowed to return, 
brought no fecal matter, but the last that flowed contained two shreds, the 
largest about one inch in length by two lines in width, resembling matted 
and nucleated epithelial cells. It was believed that they were composed 
of such cells, with perhaps some of the mucous membrane to which they 
were attached, and that they were detached from the invaginated portion. 
An opiate mixture was now prescribed, to be given sufficiently often to 
relieve any restlessness, and keep the patient quiet, and a flaxseed poul- 
tice was applied over the abdomen. On the following day the tempera- 
ture was 103|- , pulse 158, and the abdomen somewhat distended; but 
the vomiting had ceased, and there had been two fecal evacuations since 
our last visit. The intussusception had been relieved, the inflammatory 
symptoms soon abated, and the infant's health was fully restored. 

Injections in order to be effectual, and give promise of success, must be 
aided by gravitation. Unless the nates are so elevated as to obtain the 
benefit of this hydraulic principle, I am convinced that inflation is more 
likely to reduce the displacement, and if, after sufficient trial of injections, 
relief is not obtained inflation should be employed. Inflation produces an 
equable and effective distension of the external or incarcerating portion of 
intestine, and cases of cure by inflation have been reported after injections 
had failed. Treatment by inflation, which indeed ought to occur to any 
intelligent physician, appreciating the anatomical condition of the parts, 
as the correct mode, was prominently brought to the notice of the profes- 
sion in modern times by Mr. Samuel Mitchell, in a communication to the 
London Lancet for March 17, 1838. 

" I take the liberty," he writes, " of suggesting to the profession, through 
the medium of your valuable periodical, the trial of inflating the bowels 
by means of a glyster-pipe attached to a common pair of bellows ; it has 
fallen to my lot to witness several of these most distressing cases in chil- 
dren ; the nature of the obstruction was foretold during life, and unfortu- 
nately verified by post-mortem examination. The last case of the kind 
which came under my care, about two years since, presented all the usual 
symptoms : intolerable restlessness, the most obstinate sickness, the singu- 
larly distressed state of countenance, and shrunken features. The usual 
remedies were had recourse to, viz., warm baths, glysters, anodyne fric- 
tions over the abdomen, etc., but without avail. As a forlorn hope I made 
trial of inflation by the above means, with the most happy result. The 



TREATMENT, 707 

sickness immediately ceased ; the child within an hour passed a natural 
stool, and in the morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet, but it is really as 
old as the time of Hippocrates, who speaks of throwing air into the bowels, 
by which flatulence is imitated (flatus immitatur). (Hippocrates' Works, 
translated from the Greek by Grimm, 4 bd., page 198.) Haller also re- 
commended the same treatment : " Flatus etiam immissus celerrime suscep- 
tionem dispellet." (Physiologia Corporis Humani, torn, vii, p. 95.) In the 
Edinburgh Medical Journal, October, 1864, Dr. David Greig relates five 
cases of successful treatment of intussusception by inflation. The first, an 
infant six months old, previously in good health, suddenly became very 
fretful, apparently having severe paroxysmal pain in the abdomen. She 
had vomiting, and finally tenesmus, with bloody evacuations. Warm 
water enemata could not be employed on account, the writer thinks, of 
the spasmodic action of the intestines, and an abdominal tumor could 
be distinctly felt near the umbilicus. Castor oil and a purgative powder, 
and enemata of water having been employed in vain, and the case becom- 
ing really critical on the second day, inflation was resorted to. The writer 
says : " The nozzle of a small pair of bellows was introduced into the anus, 
and air injected to a considerable extent. Contrary to our expectation, 
the air passed readily into the bowel, and seemed to give the child great 
relief. After the injection it lay very quiet, as if asleep, and evidently 
quite free from pain. In about twenty minutes from the time the air in- 
jection was administered, a slight rumbling noise was heard in the child's 
abdomen, followed by a crack so loud and distinct as to alarm the attend- 
ants in the room, who thought something had burst in the child's bowels. 
The child, however, continued as if asleep, and free from pain, and in 
about half an hour a large feculent stool, slightly mixed with blood and 
mucus, was passed without pain. During the night the child rested pretty 
well, had no return of vomiting, took the breast as usual, and in two days 
was quite well." 

Another child, nine months old, treated by Dr. Greig, presenting nearly 
the same symptoms and the abdominal tumor, also obtained relief by in- 
flation, after castor oil and enemata had failed to produce any benefit. 

An apparatus for the production and injection of carbonic acid gas has 
been invented by Schultz and "Warker, of this city, and is manufactured 
by them. It consists essentially of two glass chambers, one over the other. 
In the lower one a bicarbonate is placed, and in the upper an acid in a 
liquid state. By the gradual admixture of the two, carbonic acid is set free. 
An elastic tube conveys the gas from the lower chamber. The apparatus 
has been used by physicians of the city for the reduction of intussuscep- 
tion and other purposes, and is a useful invention. 

The same firm , and several others in this city, prepare for the shops 
large bottles of highly charged carbonic acid water, from which when 



708 INTUSSUSCEPTION". 

inverted a powerful current of carbonic acid gas can be obtained. Two or 
three of these bottles, with a portion of the tube from Davidson's syringe, 
which can be readily attached to the stem from which the gas escapes, 
constitute all that is required for an ordinary case. 

The following cases, which I treated with Dr. Bitchier, of this city, in 
1871, show what may be achieved by inflation, and also the unfavorable 
result which must inevitably occur in certain cases. A German infant, 
five months old, nursing, began to be fretful, crying often on March 7th, 
and before night passed a scanty motion of blood. The symptoms con- 
tinuing, I was asked to examine the infant on the 10th, and learned the 
following facts : It had vomited daily, had had daily scanty but infrequent 
stools, consisting chiefly of blood, accompanied at first by tenesmus, but 
not within the last day; it continued to nurse, but was becoming thinner 
and weaker, and was evidently in pain. The symptoms indicating the 
nature of the disease, the abdomen, which was not distended, was ex- 
amined for the tumor, which was found in the right side in the site of the 
ascending colon, apparently about one and a half to two inches in length ; 
pulse 124 in sleep; no cough. An ineffectual attempt was made to reduce 
the intussusception by a very rude and imperfectly constructed apparatus 
(the bellows), when from the lateness of the hour farther treatment was 
postponed till early the following morning. 11th. Tumor still detected 
in the right lumbar region; pulse 120 asleep, 150 awake. By means of 
Schultz and Warker's apparatus, the intestines were inflated so as to pro- 
duce very decided prominence of the abdomen, and the abdomen gently 
kneaded. After some minutes the gas was allowed to escape, when the 
tumor had disappeared. In a few hours, a natural evacuation occurred 
from the bowels, and the infant has remained well since. 

The second case ended unfavorably, although the symptoms were appa- 
rently no more grave than in the case just related, and had continued a 
shorter time. This infant was also of German parentage. The tumor, 
firm and elongated, could be distinctly felt in the left lumbar region. In 
this case the inverted bottles of carbonic acid water were employed, and 
when, after considerable delay and kneading of the abdomen, the gas was 
allowed to escape from the intestine, the tumor had disappeared. A few 
hours afterwards convulsions occurred, ending fatally. At the autopsy the 
invaginated mass, which was too firmly strangulated to admit of reduction 
by inflation, was found in the epigastric region, having been carried up 
from its former position by the inflation of the intestine below. It con- 
sisted of the terminal part of the ileum, which had passed through the 
ileo-coecal orifice, and become incarcerated in the ascending colon, and, as 
is not unusual in these cases, the action of the intestines had changed the 
location of the tumor in the abdomen from the right to the left side. 

Whether air or carbonic acid is employed, it is necessary to produce 
distension of the intestine to its fullest extent below the seat of the com- 



TREATMENT. 709 

plaint, without endangering rupture, and of course the sooner it is used 
the better the chance of success. In a few days the displaced intestine 
has, in a large proportion of cases, become so firmly incarcerated, and has 
descended so far, that attempts to replace it, either by injections or infla- 
tion, are unsuccessful; still, even at a late period, a persevering attempt 
should be made if it has not previously been tried. If injections and in- 
flation fail to effect the desired result, the employment of quicksilver, by 
the rectum with the thighs elevated, has been suggested to me as worthy 
of trial by a physician of large practice in this city, who has had con- 
siderable experience with intussusceptions. This may be a useful sugges- 
tion, especially if the invagination is in the descending colon. 

If the modes of treatment which I have recommended above, fail to 
give relief when perse veringly and sufficiently employed in a case of acute 
intussusception, the patient's state is one of extreme peril, and the prog- 
nosis is unfavorable. Yet recovery is possible in one of two ways, namely, 
by incision through the abdominal walls (laparotomy), and reduction of 
the displacement by the fingers within the abdominal cavity; and secondly, 
by sloughing of the invaginated mass, and union by adhesive inflammation 
of the ends of the intestine which have preserved their vitality. Atrophy 
of the imprisoned part so seldom occurs in a case which has resisted in- 
jections and inflation, that it need not be considered in this connection, as 
a mode of recovery. 

Laparotomy has been successfully performed in a child aged two years, 
as I have stated above, by Dr. Jonathan Hutchinson, of London. The 
case was one of those exceptional ones in which great displacement had 
occurred without strangulation. It had continued as indicated by the 
symptoms about, one month, and a portion of the intestine terminating in 
the ileo-crecal valve had extended several inches from the anus. " The 
patient was anaesthetized by chloroform, and the abdomen was opened in 
the middle line below the umbilicus. The intussusception was then easily 
found, and as easily reduced. The after-treatment consisted only in the 
administration of a few mild opiates, and the child made a rapid recovery.'' 
(See London Lancet, November 22, 1873.) In a case of this kind, there 
can be no doubt of the propriety and necessity of laparotomy as a last 
resort, for there being no strangulation, sloughing could not occur, and 
death sooner or later, from exhaustion, must be the inevitable result. 
Cases of this sort have usually been left* to perish, after the ordinary modes 
of relief have failed. Thus as far back as 1784, M. Robin published in 
the Mem. de V Acad, de Chirurg., the case of a child aged 3-^- years, who 
died after the lapse of three months, with a caecum protruding from the 
anus. And in the Amer. Journ. of Med. Sci. for 1849, Dr. Worthington 
published a similar case, in which a child aged three years and four 
months lived even a longer time. In these days of anaesthetics, and with 
the brilliant success of Hutchinson, a physician would in my opinion be 



710 INTUSSUSCEPTION. 

reprehensible if lie allowed a child aged two years or over, with this form 
of the displacement, to perish without strongly advising laparotomy. 

But the question arises, whether in those more frequent cases of intus- 
susception in young children, in which, after the displacement has con- 
tinued a few hours, there is such firm constriction of the invaginated mass, 
that the patient suffers much pain and constitutional disturbance, and 
probably passes bloody stools, and injections and inflation have failed to 
reduce the displacement, laparotomy is justifiable. This operation, in the 
case of infants, has heretofore been regarded as so dangerous, and so likely 
in itself to prove fatal, that the profession have generally considered it 
unjustifiable, believing that, although death was nearly certain without it, 
the performance of it did not increase the chances of a favorable result. 
Dr. J. B. Sands, of New York, has recently shown that laparotomy is 
justifiable, as a last resort, for the relief of this form of intussusception, 
even in the youngest infants ; and in the following case, recorded in the 
New York Medical Journal, June, 1877, saved the patient, who doubtless 
would otherwise have perished. 

On March 11, 1877, an infant of six months suddenly presented the 
characteristic symptoms of intussusception, such as tenesmus, abdominal 
pain, vomiting, and bloody stools. A few hours later, when Dr. Sands 
was called, the pulse was rapid and feeble, with symptoms of collapse. 
An elongated tumor could be felt in the abdomen, extending from the left 
iliac region to the left hypochondrium, inelastic, tender on pressure, and 
dull on percussion. The lower end of the invaginated mass could be 
readily touched by the finger introduced into the rectum. The usual 
methods to effect reduction were at once employed with partial success, 
for the tumor disappeared from the site where it had been discovered, and 
was reduced to a small and firm mass, on a level with the umbilicus, but 
it resisted any further attempts to effect its reduction. 

Dr. Sands, then having etherized the patient, made an incision in the 
median line of the abdomen, extending downward about two inches from 
a point a little below the umbilicus. Through this opening, proceeding 
cautiously, and using as little violence as possible, he was able after some 
delay to reduce the displacement. The invaginated mass, which was only 
one and a half inches in length, consisted of the terminal portion of the 
ileum and the cascum, which had entered the ascending colon. The wound 
was closed by five silver sutures, which embraced the peritoneum, and the 
patient made a good recovery. The operation was performed eighteen 
hours after the commencement of symptoms. 

Dr. Sands has collected the statistics of twenty cases of laparotomy for 
intussusception occurring at different ages, in wiiich the result was stated. 
Of these, seven recovered, or one in three ; but he judiciously remarks, 
considering the gravity of the operation, that it is doubtful whether future 
statistics will show so favorable a result of laparotomy for this displacement 



TREATMENT. 711 

as to justify the frequeDt use of the knife. For facts and statistics relating 
to this subject the reader is referred to an elaborate paper by Dr. Ashhurst, 
published in the American Journal of the Medical Sciences for July, 1874. 

It is obvious that the earlier the displacement is recognized, the greater 
the probability of the reduction by the judicious use of injections and infla- 
tion, and it is seen from cases related above that this treatment may be 
successful as late as the second or third day, after previous attempts to 
reduce the intussusception by the same means have failed, and when there 
is that degree of strangulation that bloody stools occur. But as my own 
experience has shown me, there is also inevitably a large proportion of 
cases in which the use of injections and inflation, however judiciously and 
perseveringly made, totally fail, and it seems to me, in the light of present 
experience, that when pressure from below by water, air, or gas, which is 
the only efficient mode of treatment short of the knife, has been tried suffi- 
ciently long and often without result, that it is the duty of the physician 
to seek surgical advice in reference to laparotomy, as he would in a case 
of hernia, especially since, under Lister's antiseptic method, the danger 
from severe operations, appears to be considerably diminished. It may be 
added that laparotomy performed on the first or second day will be much 
more likely to save life in ordinary cases than if performed later, since the 
strangulated intestine is soon badly damaged, and a local peritonitis is apt 
to be developed any time after the first forty-eight hours. 

When an intussusception has reached that stage in which active inter- 
ference is no longer proper, the physician can only prescribe opiates, 
with sustaining measures and an emollient poultice over the abdomen, and 
must await the result. The diet should consist of beef juice and other 
concentrated nutriment, which leaves little residuum. Vomiting, which 
is so common, is best controlled by bismuth and opiates ; convulsions re- 
quire the bromide of potassium, and an enema of three to five grains of 
chloral hydrat, dissolved in a little water. 



SECTION IV. 
DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTER I. 

CYANOSIS. 

Certain of the diseases which pertain to the circulatory system have 
been treated of in other parts of this book (umbilical hemorrhage, gastro- 
intestinal hemorrhage, etc.). It remains to consider that general condi- 
tion of the blood which is designated morbus creruleus or cyanosis. 

In 1863, I read before the New Y'ork Academy of Medicine a statistical 
paper on cyanosis, which was published in the Transactions of that Society. 
This paper contains an .analysis of 191 cases, collated from the various 
European and American medical journals, and to these cases I am indebted 
for most of the following facts pertaining to this disease. 

The term cyanosis or blue disease is differently employed by writers. 
Some apply it to cases of transient lividity occurring in the course of acute 
diseases, as well as to those cases which depend on permanent structural 
changes, or on malformations. I apply this term, as do most pathologists, 
only to the latter cases. 

Some are inclined to discard the consideration of cyanosis as a disease, 
regarding it rather as a symptom. Their view is, in my opinion, correct 
in reference to the cyanotic state which occurs in certain acute diseases, 
but not in reference to cyanosis, as I have defined the term and employ it. 
The propriety of considering cyanosis a disease is more apparent if we are 
not misled by the term which designates it. Lividity is not its most im- 
portant or its essential characteristic. It is simply a sign, although con- 
spicuous, and, indeed, the only one by which the disease can be readily 
recognized. Cyanosis is, in reality, a blood disease, its pathological state 
consisting in a deficient oxygenation of this fluid, or in an excess in it of 
carbonic acid, and probably of carbonaceous products. It should be 
placed in the same category with leucocythsemia and melanaemia. 

Statistics show that cyanosis is, with very few exceptions, due to malfor- 
mation in the circulatory system., and at the centre of circulation, namely, 
in the heart and in the large vessels which arise from this organ. In ex- 
ceptional cases the cause of the cyanosis is located in the lungs, and is 



LITERATURE OF CYANOSIS. 713 

in all or nearly all instances either extensive emphysema in both lungs, 
firm and thick fibrinous exudation over both lungs, compressing them by 
its contraction and causing, perhaps, carnification in parts of them, or the 
cause is compression of the lungs from caries of the vertebrae, and conse- 
quent depression of the ribs. These causes pertain to youth and manhood 
rather than to infancy and childhood. On account of this fact and the 
rarity of such cases they need not be considered in this connection. 

Literature of Cyanosis. 

The ancient physicians, so far as can be ascertained from their writings 
still extant, were ignorant of cyanosis ; whether they overlooked it, or 
whether those early ages were exempt from it and the malformation on 
which it depends is peculiar to a posterity physically degenerate. The 
blue disease described by Hippocrates (De Morbis, lib. ii, sec. v, page 485, 
Ed. de Foe's, 1621) was probably some acute febrile affection. Galen, 
whose voluminous writings, with an excellent index, are still extant, and 
whose comprehensive mind embraced the whole range of medical science 
of the second century, makes no mention of it, so far as I can find. In 
the middle ages, as appears from a remark of Boerhaave (Diseases of the 
Humors, Acad. Lect., § 732), the common people believed the cyanotic to 
be the victims of evil spirits ; and it is probable that physicians, during 
this long period of superstition and intellectual lethargy, embraced the 
popular belief. 

On the revival of learning, pathological anatomy began to be more 
thoroughly and intelligently studied ; but it is evident that before the 
great discovery of Harvey, in the 17th century, it was impossible to refer 
cyanosis to its true cause. In the latter part of the century so auspiciously 
opened by Harvey's genius, malformations of the heart were observed and 
described by some pathologists on the continent, in cases in which cyanosis 
must have been present ; but it is uncertain, from the brief records which 
they have left, whether any of them understood the dependence of this 
disease on the abnormal state of the heart. Boerhaave, in the beo'innin£r 
of the 18th century, attributes " a livid or black color diffused throughout 
the whole skin," evidently referring to cyanosis, to "1, a relaxation of the 
vessels, while the vis a tergo remains the same, or, 2, to a too sudden 
increased pressure behind, without a relaxation of the vessels." Vieus- 
sens, who was a contemporary of Boerhaave, and was more thorough in 
the examination of morbid as well as healthy structures, narrated the 
history of a cyanotic patient, with a description of the malformation, but 
the one who first gave particular attention to the blue disease was Mor- 
gagni. This Paduan professor, far excelling his predecessors in thorough- 
ness of observation and accuracy of deduction, published a theory in 
explanation of the disease which now, after the lapse of more than a 



714 CYANOSIS. 

century, has many adherents. In the same century with Morgagni, the 
18th, but subsequently to his time, Drs. Pulteney, Wm. Hunter, Baillie, 
Wilson, and Abernethy in Great Britain, and Jurine and Sandifort on 
the continent, may be mentioned among those who contributed to a knowl- 
edge of cyanosis by the publication of cases, with a description of the mal- 
formations. Yet, when the present century commenced, no monograph 
or dissertation had appeared on this disease ; and, notwithstanding the 
publication of cases from time to time, the profession generally were 
almost totally unacquainted with its nature. No better idea can be given 
of the prevailing ignorance, in reference to cyanosis at this period, than 
by quoting from a case related by Ribes in 1814. (Bull, de la Fac. de 
Med., 1815.) The patient had some time previously received an injury 
of the finger. "Many physicians of Amsterdam," says he, " were at dif- 
ferent times consulted on the subject of this affection, no one of whom 
understood its true cause, its essential character. One considered it as 
partaking of the nature of epilepsy, and caused by the irritation in the 
nervous system which the wound in the finger had produced. Others 
attributed it to the presence of intestinal worms. Some physicians pro- 
nounced it an injury of the liver or spleen. Many held it to be a scor- 
butic affection. One only believed it to be the result of an unknown 
organic disease." 

Since the commencement of the present century the blue disease has 
received a large share of attention. According to Forbes' s Medical Biog- 
raphy, the first dissertation on this subject appeared in 1805, from the pen 
of Seiler, and from this time till 1832 no fewer than twenty-eight disser- 
tations or mongraphs were published, either on cyanosis or on malforma- 
tions which produce it or at least relate to it. In the list of writers are 
some of the most eminent names in the profession, as Louis and Bouil- 
laud. The number who have written on this subject since 1852 probably 
exceeds the number of previous writers. Of those who have contributed 
most to our knoweldge of the disease may be mentioned Farre, Che vers, 
and Peacock in Great Britain, Gintrac on the continent, and Moreton 
Stille in this country. Farre, Chevers, and Peacock wrote on malforma- 
tions of the heart, alluding incidentally to cyanosis, but their writings 
contain valuable matter for statistics bearing on the latter subject. 
Farre's book was published in 1814, and is out of print; Chevers pub- 
lished his papers in the London Med. Gazette, commencing in the year 
1845 and running through several successive volumes. Peacock's treatise 
was published in 1858. It contains several original cases, previously nar- 
rated by him to the London Pathological Society. The paper by Moreton 
Stille, which has attracted much attention, especially in Europe, was his 
inaugural thesis, and was published in the Amer. Med. Journ. of Med. Sci. 
in 1844. This paper relates entirely, in the words of the author, to "the 
laws of the causation of cyanosis." The only really complete statistical 



CAUSES OF THE MALFORMATIONS. 715 

paper on the blue disease is that by M. Gintrac, published in 1824, in 
Paris, and embracing all the cases which had been accurately reported up 
to that time, namely, fifty-three. He, indeed, exhausted the subject for 
the period in which he wrote, but on account of the accumulation of ma- 
terial since, his monograph now seems incomplete. 

Two theories in explanation of the occurrence of cyanosis have divided 
the profession : the one attributing it to obstruction at the centre of circu- 
lation, and consequent venous congestion; the other, to admixture of venous 
and arterial blood through openings in the septa of the heart, or through 
the ductus arteriosus. The former of these theories originated with Alor- 
gagni more than one hundred years ago, and is essentially the same as that 
advocated by Stille. Stille errs in placing Morgagni among the advocates 
of the other system. The second theory, or that which attributes cyanosis 
to admixture of venous and arterial blood, is said by Dr. Peacock to have 
originated with Hunter, but its ablest supporter was Gintrac. Of late 
there are some pathologists who do not believe that either theory is suffi- 
cient to explain the cause of cyanosis, but that the true explanation lies 
somewhere between the two. Among the most conspicuous of these is 
Prof. \Yalshe, of London. These theories will be considered in the proper 
places. 

Sex. — Writers on cyanosis state that there is a preponderance of males 
to females affected with it. Aberle, of Vienna, says that two-thirds were 
males in an aggregate of 180 cases which he collated. In Gintrac's cases, 
28 were males and 16 females; in Stille's, 11 were males and 31 females. 
The sex is recorded in 131 of the cases collected by me, of which 78 were 
males, 56 females; and if those cases are excluded in which cyanosis was 
due to obstruction at the mouth of the pulmonary artery, the number of 
the two sexes is the same. In the five years commencing with 1858, 
according to the mortuary returns, 207 died in this city from cyanosis, of 
which number 117 were males, 90 females. In England, for two years, 
418 males died of cyanosis, and 273 females. Although statistics of dif- 
ferent cities and countries agree in the fact of an excess of males over 
females, there does not appear to be that great preponderance of males, 
which the earlier writers on this disease believed to exist. 

Causes of the Malformations — Mothers sometimes attribute the 
malformations, and probably correctly, to strong mental impressions felt 
during utero-gestation. The mother of a patient treated by Dr. Peacock 
stated that "two months before her confinement, she was frightened by 
seeing a child killed, and never recovered from the shock she sustained." 
{Malf. of Heart, p. 37.) In another case "the mother was much out of 
health, and stated that, when pregnant Avith the child, she was greatly 
alarmed by seeing a man who was dying of asthma." (Op. cit., page 57.) 
In another instance the mother was frightened at the fifth month of preg- 
nancy (page 41); and in still another case, recorded by Dr. Peacock, the 



716 CYANOSIS. 

mother, four or five months before her confinement, "was greatly alarmed 
by her husband, who was insane, standing over her for ; two hours with a 
loaded pistol." (Page 43.) 

Occasionally the malformation appears to be due to some vice or taint 
in the system of one or both parents. In a case quoted in the Gazette 
Medicate, for December 28, 1850, from another continental journal, it is 
stated that "the mother, who had formerly suffered from rickets, gave 
birth to five children, all of whom died immediately or shortly after birth 
with symptoms of cyanosis. The father died at the age of thirty-six of 
phthisis." Dr. Peacock relates a case in which the father was livid, and 
had the "pigeon-breast" common in the cyanotic. In the history of a 
patient, which was communicated by Cooper to Farre, it is related that 
"vices of conformation of the heart appeared to have been inherent in the 
family. Of 12 infants only 4 survived, and more presented signs of heart 
disease." Dr. Buchanan relates the history of a child which was the 
second that had suffered" and died in the same family in the same way. 
A patient treated by Mr. Leonard was the sixth child of the family, who 
had died at about the same age, with symptoms of cyanosis. Such in- 
stances are, however, exceptional. Ordinarily, the cyanotic have not only 
healthy parents but healthy brothers and sisters. 

A patient whose history is given by Dr. William Hunter was born at 
the eighth month, but in nearly all other cases the full period of intra- 
uterine existence was reached. 

The opinion was expressed by Gintrac that the number affected with 
cyanosis, to the entire population, varies in different countries. It is 
probable that the occurrence of the blue disease is not greatly, if at all, 
influenced by the nationality, but it is certainly dependent to a consider- 
able extent on the condition of society. It is less frequent in a community 
in comfortable circumstances, and engaged in wholesome and quiet occu- 
pations. Pure air and outdoor exercise, plain, nutritious diet, freedom 
from cares and anxieties, in fine, causes which promote the physical well- 
being, diminish the liability to an ill-formed and cyanotic offspring. And, 
conversely, impure air, improper and insufficient diet, grief, etc., increase 
the percentage of cyanotic cases. Hence, it is a rare disease in the rural 
districts, and comparatively frequent in the cities, especially in a large 
city like New York, which contains a numerous indigent and careworn 
population, living from year to year in the midst of agencies which ope- 
rate stealthily but certainly to enervate the system and undermine the 
health. 

These remarks are abundantly substantiated by statistics. In New 
York city for the six years ending with 1860, there was one death from 
cyanosis to 436 deaths from all causes; and in Brooklyn the proportion 
estimated for two years was about the same. On the other hand, in the 
State of Kentucky, which contains few large cities, and in the death re- 



TIME OF COMMENCEMENT. 717 

\ orts of which cyanosis is included in the general term malformation, 
there was, during a period of five years, one death from malformation to 
24G9 from all causes. In the State of South Carolina, for three years, 
there was one death from cyanosis to 5018 from all causes. In the State 
of Massachusetts, for two years, there was one death from cyanosis to 113G 
from all causes, and two-thirds of the cyanotic cases occurred in the 
counties of Suffolk, Essex, and Worcester, which contain large cities. In 
London there was one death from cyanosis to 755 from all causes during 
a period of three years. On the other hand, in England, including the 
city of London, there was, for the ten years ending with 1857, one death 
from cyanosis to 1589 from all causes; and in the rural districts of Mon- 
mouth and Wales there was only one death from cyanosis to 5578 deaths 
from all causes during a period of two years. 

Time of Commencement — It is an interesting and somewhat remark- 
able fact that cyanosis, though dependent on a malformation, does not 
always commence at birth, or, at least, that it .does not exist in degree 
sufficient to produce the cyanotic hue till some time has elapsed after 
birth. In 138 of the cases of cyanosis which I have collected, the time 
at which lividity was first observed is stated as follows: In 97 it was 
within the first week, and generally within a few hours of birth. In the 
remaining 41 cases it commenced as follows : — 

In 3 at 2 weeks. In 6 from 2 years to 5 years. 

" 1 " 3 " "1 " 5 " " 10 " 

"2" 1 month. " 6 " 10 " " 20 " 

" 7 from 1 to 2 months. "1 "20 " "40 " 

"5 " 2" 6 " " 1 over 40 years. 

" 5 " 6 " 12 " — 

"3 " 1 year to 2 years. 41 

In these 41 cases, in which blueness did not occur till after the a»-e of 
one week, if the patient were less than two years old when it commenced, 
there was frequently no obvious exciting cause, but above this a°-e, with 
three exceptions, such a cause is known to have been present. It is in- 
teresting to observe how trivial the exciting cause frequently is, and 
equally interesting to note how long patients have enjoyed good health, 
not having the least lividity, although the anatomical vice, to which the 
final development of cyanosis was due, had existed from birth. 

Dr. Theophilus Thompson relates, in the Medico- Chir. Trans., vol. 
xxv, the history of a lady, thirty-eight years old, who was well till an 
attack of Asiatic cholera, after which her health was permanently im- 
paired. Two years before her death she passed through a course of fever, 
and from this time was cyanotic. In the Philadelphia Medical Examiner, 
June, 1850, Dr. Waters relates a case, in which cyanosis began at the age 
of six years in an attack of measles. In a case published by Mr. JNapper, 
in the London Medical Gazette, 1841, the child fell at the age of six 



718 CYANOSIS. 

months, and from this time had cyanosis. A female, whose history is 
given by Prof. Tommasini, of Bologna, and quoted by Bouillaud, became 
cyanotic at the age of twenty-five in consequence of difficult parturition. 
In the London Lancet, 1842, Mr. Stedman relates a case, in Avhich cya- 
nosis began at the age of ten weeks in an attack of convulsions. In the 
American Journal of Medical Sciences, 1847, Dr. John P. Harrison pub- 
lished the history of a baker, twenty years old, in whom cyanosis began 
five years previously after great effort in carrying wood. Louis and 
Bouillaud quote from M. Caillot the case of a child, who became cyanotic 
at the age of two months in an attack of hooping-cough. Louis also nar- 
rates a case in which hooping-cough had the same effect at the age of 
twelve years. Ribes treated a child in whom the blue disease began at 
the age of three years from a severe contusion of the fingers. In a case 
related by Marx it commenced at the age of ten months from a blow on 
the back, inflicted by the mother. In the Medical Times and Gazette, 
for 1855, Mr. Speer gives the history of a female, who at the age of thir- 
teen years was put in a place requiring considerable exertion, and from 
this time was cyanotic. A patient, whose case is related by Cherrier, 
fell into a deep ditch in the winter season, and immediately after had a 
low fever, from which the blue disease commenced. In a case published 
by Tacconus the exciting cause was believed to be fright, in consequence 
of a fall from a great height, and in another, related by Bouillaud, it was 
a blow received on the epigastrium after the patient had passed the age of 
fifty years. Similar cases are related by Mayo and Peacock. 

It will be seen that the exciting cause of cyanosis is usually such as pro- 
duces a profound impression on the system, and affects the action of the 
heart. Precisely in what way it operates to develop the disease has not 
been satisfactorily explained. Mr. Mayo conjectures, that in the case re- 
lated by him there was previously some compensation which ceased, or be- 
came inadequate in consequence of some change produced in the economy. 
Although cyanosis may not appear for months or even years, there is rarely 
improvement when it is once established. Appearances of amendment are 
deceptive. The disease when not stationary is progressive, and this ex- 
plains the fact, that few survive the middle period of life. 

Symptoms The symptoms of cyanosis vary in intensity in different 

j atients, and in the same patient at different times, being milder if he is 
quiet and the mind calm, more severe if active, or if the mind is agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that a 
stranger would not suspect that there was any serious ailment. They are 
aggravated by any cause which accelerates the action of the heart. In 
some, cyanosis is increased by the most trivial disturbing influences, 
among which may be mentioned nursing, dentition, crying, coughing, and 
slight emotions of joy, sorrow, or anger. In more than one case it has 



SYMPTOMS. 719 

been perceptibly increased by the stimulus of digestion, the color being 
deeper after a full meal than before. 

The cyanotic hue varies in different individuals from duskiness to a 
deep purple, almost black color. It is usually most marked in the visage, 
especially the palpebral, cheeks, nose, and lips, in the ears, fingers, and 
toes, and upon the mucous surfaces. It is sometimes, without any assign- 
able cause, confined to a portion of the body. In a case related by Mr. 
Steel in the London Lancet, 1838, the upper part of the body was livid 
and oedematous, and the lower part pallid and shrunken, and yet the mal- 
formation was of the kind which is commonly present in cyanosis. In the 
London Medical Times. March 8, 1845, copied from the Gazette Medi- 
cate, is the history of a child six years old, in whom the color was deeper 
on the right than left side. There had been, however, hemiplegia of this 
side in infancy, but this had entirely passed off. On the other hand, in a 
case of rare malformation communicated by Cooper to Farre, in which the 
upper part of the system was supplied chiefly by arterial and the lower by 
venous blood, the discoloration was general. In exceptional instances livid 
maculae, like those of purpura, have been observed upon the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases, for a considerable period after 
birth, the appetite is good, bowels regular, and the system well nourished. 
But when cyanosis becomes so severe, as it does sooner or later, that its 
symptoms are rarely absent, digestion is imperfectly performed, and the 
body becomes either emaciated or stunted and puny. It may be stated, 
as a rule, that nutrition is in inverse proportion to the gravity of cyanosis. 
In thirty -three out of forty-one cases, in which the condition of the system, 
as regards nutrition, was recorded either a short time previously to death 
or at the autopsy, the body was either considerably emaciated or else 
diminutive, and those who were well nourished were usually such as had 
died early, or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have 
been observed in the cyanotic. The chest is often flattened laterally with 
a projecting sternum, so as to present an appearance generally described 
in the records as "pigeon-breasted." Sometimes the most prominent 
part is directly over the heart, and in one or two cases the sternum was 
observed to be deflected towards the left. In the majority of the records, 
however, no mention is made of the external appearance of the chest. 

The other abnormal development is more remarkable, and has not been 
satisfactorily explained. In twenty-eight cases it is stated that the tips of 
the fingers or toes, or both, were bulbous. This hypertrophy, if slio-ht, is 
likely to be overlooked, and that it was observed and recorded in so many 
cases renders it probable that it was present in a much larger number. In 
one case the anatomical character of this enlargement was examined, and 
was found to consist chiefly of hypertrophied connective tissue. The nails 



720 CYANOSIS. 

are often incurvated over the deformity. At a meeting of the Lond. Path. 
Soc., in 1859, Mr. Ogle narrated the history of a laborer, fifty years old, 
who had swelling, numbness, and lividity of the left arm, from pressure of 
an aneurism, and the fingers on this side were clubbed as in cyanosis. A 
patient whose history is related in the Glasgow Medical Journal, and who 
was believed to be cyanotic in consequence of a highly emphysematous 
state of the lungs, had a similar development of the tips of both fingers 
and toes. Why this bulbous growth should occur in consequence of the 
circulation of non-oxygenated blood is unknown. 

An interesting feature in cyanosis is the low grade of animal heat. The 
temperature of the body is in all cases below that of health. This is es- 
pecially noticeable in the extremities. There has not been a sufficient 
number of accurate thermometric observations to determine whether the 
internal heat is usually reduced. The following only have been recorded : 
Mr. Fletcher relates the history of a young man in the Medico- Chir. 
Trans., vol. xxv, in whom the thermometer placed in the mouth did not 
stand above 80° Fahrenheit. Hodgson reports the case of a man, twenty- 
five years old, in whom the thermometer placed on the tongue rose to 
100°, while in his own case it was two or three degrees below that term. 
In an experiment, recorded by Nasse, the instrument placed in the mouth 
fell little if at all below r the healthy standard ; applied to external parts, it 
stood at about 21° Reaumur. 

The lack of heat is the source of great discomfort to a cyanotic patient. 
In mild weather he requires a fire to keep him warm, or an amount of 
clothing which to others would be intolerable, and in cold weather slight 
exposure strikes him w T ith a chill. Nor can he increase his heat by active 
exercise, since his infirmity disqualifies him for this. 

Although the temperature of the surface is so low, the occurrence of 
perspiration, sometimes profuse, is mentioned in several of the records. 

In severe cases of cyanosis the generative system is imperfectly devel- 
oped. In the female, menstruation is scanty or delayed, and in the male 
signs of puberty are feebly manifest. If the disease is so mild that the 
symptoms are absent when the patient is in a state of repose, these 
organs attain nearly or quite their normal development. The catamenia 
have appeared as early as the age of sixteen years; and a cyanotic patient 
treated by Cherrier had two children, but they both died of scrofulous 
affections. 

The action of the heart is necessarily much affected. In mild forms of 
the disease, if the patient is quiet, this organ may beat with considerable 
slowness and regularity, but in all cases exercise or excitement, which in 
a state of health would scarcely have any appreciable effect on the pulse, 
embarrasses its movements, and produces palpitation. In severe cases 
palpitation is rarely absent, and the pulse is frequent, feeble, and often 



SYMPTOMS. 721 

intermittent. In a large proportion of patients bruits are produced by the 
irregular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accele- 
rated in proportion to the frequency of the pulse. The suffering in this 
disease is largely due to paroxysms of palpitation and dyspnoea. These 
occur sometimes without any apparent exciting cause, and when the patient 
is quiet, but they are commonly induced by those causes which Ave have 
already mentioned as aggravating the symptoms of cyanosis. They come 
on suddenly, and are attended by increase of lividity, distension of the 
jugulars, and sometimes of the cutaneous veins, and by a sensation of 
present suffocation. They last only a few minutes, and are succeeded by 
great depression of the vital powers. In infants, on account of greater 
nervous irritability and feeble power of endurance, these paroxysms gene- 
rally end in convulsions, which occasionally are fatal. A cough is some- 
times present, but is usually slight. 

Pain is not a common symptom. Some of the patients complain occa- 
sionally of headache, with or without vertigo, and occasionally also of pain 
in the chest, but it is uncertain to what extent or whether these symptoms 
are dependent on the cyanotic disease. The secretions do not appear to 
be affected, so far as has been ascertained. The same may be said of the 
intellectual and moral faculties. In a case related by Dr. Chevers, the 
child was even said to be precocious. (Lond. Med. Gaz., vol. xxxviii.) 
The mind is capable of steady application and acquisition, as in health, 
provided that the emotions are not unduly excited. 

Those who are affected with cyanosis are liable to various forms of 
hemorrhage, but this liability, if we may judge from recorded cases, is 
greater in youth and adult life than in infancy. In two cases blood was 
vomited, in one passed by stool, in one it escaped from the gums, in two 
from the mouth, in eight from the nostrils, and in sixteen it was expecto- 
rated. Pulmonary phthisis was, however, usually present in these last 
cases. In the Western Journal of Medicine for 1829, an interesting case 
is related by Dr. Win. M. Voris of a girl, nine years old, in whom hemor- 
rhage occurred under the scalp, producing great tumefaction, and nearly 
closing the eyelids. An incision was made, from which a pint and a half 
of dark blood escaped, and it was estimated that more than half a gallon 
was lost during the ensuing two weeks, at the expiration of which time 
the incision closed. The patient recovered from the hemorrhage, but not 
from the cyanosis. 

Towards the close of life there is occasionally more or less anasarca, 
especially around the ankles, sometimes in the eyelids and face, and rarely 
to a certain extent over the whole body. In certain patients it coexists 
with effusion in the serous cavities. 

It is evident that one who is affected with the severer form of cyanosis 
is disqualified for the duties of active life. The sports of childhool and 
46 



722 cyanosis. 

the useful labors of mature years require an exertion for which he is physi- 
cally unfit. He has not the ability even to engage in animated conversa- 
tion, for he is overcome by emotions, whether of joy or sorrow. He lives 
almost an idle spectator of the world around him, prevented by his infir- 
mity from engaging in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly tolerated ; 
but hooping-cough is the one which these patients are especially ill-fitted 
to endure. Still, they sometimes pass safely, not only through hooping- 
cough, but through some of the most dangerous febrile diseases. It is a 
question of interest, but about which little is known with certainty, whether 
these intercurrent maladies are influenced by the cyanotic or venous con- 
dition of the blood. The symptoms of these maladies are no doubt more 
alarming, mainly on account of the embarrassed action of the heart, and 
not on account of the state of the blood ; still it is reasonable to suppose 
that malignant and asthenic diseases are rendered worse by the lack of 
oxygen, and excess of carbonic acid in the circulating fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made by a high authority. Rokitansky 
says : u All forms of cyanosis, or rather all the diseases of the heart, great 
vessels, and lungs adapted to produce cyanosis, in a greater or less degree, 
cannot coexist with tuberculosis. Cyanosis affords a complete protection 
against it, and in this circumstance may be found an explanation of the 
immunity from tuberculosis which many conditions of the system, appa- 
rently very different in their character, afford" (JTandb. der. Pathol. 
Anat. II. Bd.) This opinion of the distinguished pathologist, noth with- 
standing his ample opportunities for observation and known accuracy as an 
observer, is not substantiated by statistics. So far from its being true, the 
low degree of vitality in cyanosis appears to favor the occurrence of tuber- 
cles. I have records of twenty-six cases of cyanosis in which tuberculosis 
was also present, in several of which the lungs contained cavities. This 
is about thirteen per cent, of the whole number in my collection — a large 
proportion, since so many die in early infancy, at which period the tuber- 
cular disease is not apt to occur. Cyanosis appears, also, to favor the de- 
velopment of cerebral diseases, especially congestion and coma, as will be 
seen presently. 

Prognosis — This is unfavorable. Most cyanotic individuals die young. 
The age which they attain has been made the subject of statistical inquiry 
by Aberle. He states that in an aggregate of 159 cases, 57, or 35 per cent., 
died before the end of the first year; 108, or more than two-thirds, died 
before the age of eleven years ; 30 between the ages of eleven and twenty- 
five years; and of the remaining 21, only 5 lived more than forty-five 
years. 

The age at which death occurred is given, in 186 of the cases collected 
by myself, as follows : — 



prognosis. 723 

In 17 under the age of 1 "vreek. In 21 from 5 years to 10 years. 

" 10 from 1 week to one month. "41 "10 " "20 " 

"12 " 1 month to 3 months. "20 "20 " "40 " 

"11 " 3 months to 6 months. " 4 over 40 " 

" 17 " 6 " to 12 " 

"12 " 1 year to 2 years. 186 

" 21 " 2 years to 5 " 

Sixty-seven, then, or more than one-third, died before the close of the 
first year; 121, or more than three-fifths, before the age of ten years ; only 
24 survived the age of twenty years, and four the age of forty years. Of 
course, the duration of life depends on the nature and extent of the mal- 
formations. Some of these are such as render a speedy death inevitable. 

Mode of Death The mode of death is recorded in ninety-five cases, 

as follows : — 

19 died in a paroxysm of dyspnoea. 

10 " suddenly (the exact manner not stated). 

14 " in convulsions (infants). 
2 " of apoplexy. 
7 " from hemorrhage. 
6 " of phthisis (though, as we have seen, twenty others had this 

disease). 
2 " of exhaustion, without hemorrhage. 

10 " of coma. 
2 " of abscesses in the brain. 

One died of each of the following diseases : cerebral irritation , congestion 
of brain, effusion in the cranial cavity, acute hydrocephalus, paralysis 
from acute softening of the brain, dysentery, inflammation of heart, syn- 
cope, mucus in the air-passages, thoracic inflammation, choleraic diarrhoea, 
pneumonitis, bronchitis, scarlet fever, croup. One died in trying to walk, 
one after a spasmodic cough in pertussis, one after a long agony, one after 
an agony of ten or eleven hours ; one is recorded to have died gradually, 
and three quietly. 

The ten who are stated to have died suddenly probably died in parox- 
ysms of palpitation and dyspnasa, which, we have seen, are easily excited, 
and of common occurrence in cyanosis. If so this was the mode of death 
in 29 cases. Infants, with few exceptions, so far as appears from the 
records, died in convulsions. Nineteen died of cerebral affections, ex- 
clusive of convulsions, and in thirteen of these the cause of death was 
congestion, apoplexy, or coma. The hemorrhage of which seven died 
was probably, in most instances, dependent on phthisis, and six are said 
to have died directly of phthisis. We may, then, regard paroxysms of 
palpitation and dyspnoea, convulsions, congestive affections of the brain, 
and phthisis, as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give rise to 



724 CYANOSIS. 

cyanosis are quite numerous. The following table exhibits their char- 
acter and relative frequency : — 

Cases. 
3 . Pulmonary artery absent, rudimentary, impervious, or partially obstructed 97 

2. Right auriculo-ventficular orifice impervious or contracted ... 5 

3. Orifice of the pulmonary artery, and the right auriculo-ventricular aper- 

ture impervious or contracted ........ 6 

4. Right ventricle divided into two cavities by a supernumerary septum . 11 

5. One auricle and one ventricle ......... 12 

6. Two auricles and one ventricle ........ 4 

7. A single auriculo-ventricular opening : inter-auricular and inter-ventric- 

ular septa incomplete .......... 1 

8. Mitral orifice closed or contracted 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed . . 3 

10. Aortic and the left auriculo-ventricular orifices impervious or contracted 1 

11. Aorta and pulmonary artery transposed ....... 14 

12. The cavse entering the left auricle . . . . . . . .1 

13. Pulmonary veins opening into the right auricle or into the eavae or azygos • 

veins . . . . . . . . . . . . .2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus ; pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus ..... 2 

Total "- , ... 164 

From the above table it appears that in more than one-half of the cases 
of cyanosis the congenital vice which gives rise to it is located in the pul- 
monary artery. It is located also, in general, in that part of the artery 
which is nearest the heart. Its character is different in different cases. 
Sometimes there is an arrested development of this vessel, and in its place 
we find simply a ligamentous cord extending from the heart as far as the 
ductus arteriosis, while beyond this point the artery and its branches are 
pervious ; rarely the entire artery is ligamentous and, of course, impervi- 
ous; in other cases this vessel is open through its whole extent, but the 
part nearest the heart is so small as to be properly considered rudiment- 
ary ; in others still there is adhesion of the valves to each other as the 
chief congenital defect, and, finally, in rare instances the obstruction in 
the pulmonary artery is due to an adventitious membrane, which stretches 
across the vessel like a diaphragm. These last malformations, namely, 
adhesion of the valves and the formation of an adventitious membrane, 
are, doubtless, due to inflammation occurring in the artery before birth, 
and some attribute the arrested development and ligamentous state of the 
vessel to the same cause. 

In most cases of cyanosis, due to obstructive malformations, there is 
deficiency in the inter-auricular and inter-ventricular septa. This defi- 
ciency obviously results from the obstruction, for the septa are formed in 
the heart after foetal circulation is established, and the blood, being pre- 
vented by the vicious formation from flowing in its proper channel, neces- 



MORBID ANATOMY. 725 

sarily passes to the opposite side of the heart. More or less blood being 
forced from one auricle or one ventricle to the opposite cavity, it is evi- 
dent that a permanent aperture must result in the septum. The aperture 
in the septum ventriculorum is ordinarily at its base ; in the septum auric- 
ulorum it corresponds with the foramen ovale. 

In most of the obstructive malformations one and rarely two abnormal 
cardiac murmurs have been observed. The single murmur accompanies 
the ventricular contraction. As it has been observed in cases of complete 
as well as incomplete obstruction, it seems to be due mainly to the flow of 
blood through the apertures in the septa. 

Modes of Compensation In most cases of cyanosis, the congenital 

defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmonary 
artery, and a considerable part if not all the blood flows directly from the 
right to the left side of the heart, the ductus arteriosus not only remains 
open, but is greatly enlarged, through which a current of blood enters the 
pulmonary artery from the aorta, and passing to the lungs is oxygenated. 
The bronchial arteries have also been found greatly enlarged, and it is 
believed that though they are the nutrient arteries of the lungs, the blood 
which they convey to these organs is decarbonized in its circuit through 
them. In a case published by Mr. Le Gros Clark, in the Medico- Chir. 
Trans., vol. xxx, the bronchial arteries were not only enlarged, but a 
" branch from the internal mammary artery, which accompanied the 
phrenic nerve, was nearly equal in size to the parent trunk, and expended 
itself principally in the adjacent adherent lung." Branches of the inter- 
costal arteries have also been found enlarged, and entering the lungs, or 
connecting with vessels which enter the lungs. By such modes of com- 
pensation cyanosis is rendered milder, and life is prolonged. To these we 
must attribute the fact that some have very considerable malformation, 
and yet do not become cyanotic. 

Morbid Anatomv This, as regards the circulatory system, has been 

sufficiently dwelt upon. No chemical analysis, so far as I am aware, has 
yet been made of cyanotic blood. We know that it is dark, its coagula- 
bility feeble, that it contains an excess of carbonic acid, and is deficient 
in oxygen. From the nature of cyanosis, it would be inferred that in 
many cases there is a degree of passive congestion in the cavities of the 
heart, and consequently in the capillaries of the systematic system, giving 
rise to more or less serous effusion. Statistics show that this is so. The 
quantity of pericardial fl.uid is in some patients increased. I have records 
relating to this fluid in fifty-one cases. Usually it was pure serum. In 
seventeen the quantity was half an ounce or less, if we include in the num- 
ber those in which the amount is expressed in such terms as " due quan- 
tity," " unusual amount," and " small amount." In twenty-four cases 
the serum exceeded half an ounce ; usually estimated at from one to six 



726 CYANOSIS. 

ounces, but in two it exceeded the latter quantity. In one of the twenty- 
four the serum was sanguinolent. In two cases the records state that there 
was a small quantity of blood in the pericardium, and in the remaining 
patient the two pericardial surfaces were agglutinated by inflammation. 

In some of the autopsies serum was found in the pleural cavities, usually 
in connection with pericardial effusion, and in at least one instance the 
serum was tinged with blood. Old adhesions between the costal and pul- 
monary pleura were observed in a few instances. The condition of the 
lungs was recorded with more or less minuteness in one hundred and ten 
cases. Mention has already been made of the large number affected with 
tubercular disease, which was either confined to the lungs, or was chiefly 
exhibited in these organs. In thirty-five patients the records state that 
the lungs were of small size, either by compression, or sometimes, appa- 
rently, by the continuance of the foetal state over a greater or less portion 
of the organ. The compression was produced either by the distended 
pericardium or by effusion in the pleural cavities. In thirty -five cases the 
lungs presented a dark color. This hue in some specimens accompanied 
the unexpanded or foetal state of the organ, but in others there was the 
normal inflation, and the dark color was due to engorgement or conges- 
tion. In other cases the lungs are stated to have been natural, except the 
color. In nine there was emphysema in a part of the lungs, in two pneu- 
monitis ; in two the color was pale, in one a bright crimson ; in one the 
lungs were larger than natural, in one the right lung was absent, and in 
seventeen these organs were recorded healthy. 

I have records of the state of the liver in twenty-six cases, in sixteen of 
which it was enlarged, and in four of those enlarged it was congested. 
Congestion was present in eight other cases, in which no mention is made 
of the volume. The parenchyma had a natural appearance in nine cases, 
but in some of these there was enlargement. From these statistics it is 
probable that the liver is commonly enlarged in cyanosis, and not infre- 
quently congested. In a few cases the condition of the other abdominal 
viscera is mentioned ; in some as healthy, in others as congested. There 
were fifteen examinations of the brain, in seven of which congestion is 
recorded, and in three abscesses in the cerebral substance, in one of which 
cases the lateral ventricle was also filled with pus ; in two there was soften- 
ing of a portion of the brain, in three the brain was firm or compact, in 
three the quantity of fluid in the cranial cavity exceeded the normal 
amount, and in one it was less. 

Theories Relating to the Etiology of Cyanosis — Although in 
nearly all cyanotic patients there are direct communications between the 
two sides of the heart, it is shown by many observations that these com- 
munications or apertures are not sufficient in themselves to produce cya- 
nosis. This opinion was expressed half a century ago by Louis, who 
published an excellent monograph on the subject of these communications, 



THEORIES RELATING TO ETIOLOGY OF CYANOSIS. 727 

basing his remarks on an analysis of twenty cases. Since the publication 
of this paper, the belief has been pretty general in the profession, and ob- 
servations continue to substantiate it, that, although the apertures may be 
of considerable size, if the two sides of the heart, with their orifices and 
vessels, are in their normal state, so that they act symmetrically and with- 
out obstruction, cyanosis will not occur. In proof of the correctness of 
this opinion many cases might be cited of a pervious, and some of a largely 
dilated foramen ovale without the cyanotic hue, cases which have been 
published in the journals since the appearance of Louis's monograph. 
Still, in cases of obstructive malformation, unless the obstruction is com- 
plete, cyanosis is more apt to occur in consequence of these apertures, for 
were they absent a larger amount of blood would be propelled through 
the narrowed orifice, and a larger amount consequently be oxygenated. 

Allusion has already been made to the two theories which prevail in 
the profession ; the one attributing cyanosis to the intermingling of venous 
and arterial blood ; the other to obstruction at the centre of circulation, 
and consequent venous congestion. There are serious objections to the 
acceptance of either theory as an explanation for all cases. That admix- 
ture of the two kinds of blood is not essential to the production of cyanosis, 
is apparent from the following facts. In one case in the Fourth Malforma- 
tion, there was no communication between the two sides of the heart, and 
the ductus arteriosus was closed, so that admixture was impossible. Again, 
in the Eleventh Malformation, or that in which the aorta and pulmonary 
artery are transposed, the blue disease evidently does not depend on the 
admixture of the two currents. On the other hand, in this curious state 
of the heart, the more the admixture the less the cyanosis, since the only 
way in which the systemic current of blood can be arterialized is by passing 
to the opposite side of the heart. An argument against this doctrine may 
also be found in the fact that the modes of compensation are not such as 
in any way diminish or obviate the admixture. It is admitted that in the 
more frequent malformations cyanosis is increased by the apertures, which 
allow the intermingling of the venous and arterial currents, but it is more 
reasonable to consider the intermingling and the cyanosis as the direct re- 
sults of the malformation, neither having the precedence of the other, than 
to consider that they are related to each other as cause and effect, or as 
proximate and remote results. Viewed in this light, the admixture must 
be considered simply a concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered among its 
advocates many who have given special attention to the subject, as Mor- 
gagni, Louis, and Stille, but it seems to have even less claim for accept- 
ance than the theory of admixture. It has been seen that in nearly all 
cases of cyanosis the two sides of the heart communicate freely, so that if 
the current of blood meets with an obstruction, as it commonly does, it 
readily escapes to the opposite side where the artery is large and gives it 



728 CYANOSIS. 

free passage. In this way congestion, if not prevented, is greatly dimin- 
ished. Again, it will be seen that, although certain of the viscera are 
frequently found at the autopsy more or less congested, congestion is not 
uniformly present in the organs, as it would probably be were it the prox- 
imate cause in all cases of cyanosis. 

Moreover, in some patients the malformation is not obstructive. The 
cavities and their orifices are of the normal size, and cyanosis is due en- 
tirely to malposition of the vessels. It cannot be said that in these cases 
there is venous congestion from arrest at the centre of circulation. If 
there is any congestion, it must be due to the fact that venous blood does 
not circulate as readily as the arterial in the capillaries. It is true that in 
the paroxysms of dyspnoea there is sometimes more or less congestion ; the 
distension of the jugulars show this, but it subsides with the paroxysms, 
and it probably is no more than usually occurs when the respiration is 
greatly embarrassed. 

In fine, attempts to express the immediate pathological state producing 
cyanosis in the terms of a general law have failed. However plausible the 
above theories may appear in regard to certain cases, there are others to 
which they are manifestly inapplicable. Those who advocate these theo- 
ries seem to lose sight of the obvious fact that the chief want of the economy 
in cyanosis is decarbonization of the blood, and it is hardly supposable that 
there can be any correct theory of its causation which is not founded on 
this fact. With this physiological state in view, it does not seem difficult 
to express a theory in comprehensive terms which is applicable to all 
cases, such as the following : Cyanosis is due to vices or defects in the 
organism, usually congenital, which 'prevent the free and regular flow of 
blood to, through, or from the lungs. So comprehensive a statement in- 
cludes not only cases of malformation and malposition of the heart and its 
vessels, but also those few cases in which the lungs are in fault. In most 
patients, as we have seen, the current of blood towards the lungs is ob- 
structed, and the current of blood from the lungs, in those comparatively 
rare cases in which the malformation is on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be 
warmly clad and kept in a warm room, and all agencies calculated to 
embarrass or disturb the functions of the body or excite the emotions, and 
thereby accelerate the heart's action, should be studiously avoided. The 
diet should be nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the inter- 
auricular and inter-ventricular septa, and the consequent flow of blood 
from the right to the left side of the heart, have considered it an important 
part of the treatment to keep the patient reclining on the right side, so as 
to diminish this flow by the effect of gravitation. The reader, however, 
must be convinced from the nature of the malformations that little benefit 



TREATMENT. 729 

can accrue from following such advice. Still, patients are sometimes less 
cyanotic and more comfortable in one position than another. In a case 
reported by Mr. Howship (Edin. Med. Jour., 1813), "the only easy and 
indeed comfortable position in which the child could remain was that usual 
in nursing. When erect, the dusky color of the face and neck became a 
dark-blue." In a case related by Mr. Spackman (Lond. Med. Gaz., 
1833), the patient was easiest on the hands and knees. Louis reports a 
case (de la Commun. des Car., etc.~) in which the selected position was 
with the head elevated ; Win. Hunter a case (Med. Obs. and Enq., vol. 
vi) in which the patient avoided paroxysms by lying on the left side. 
Struthers and King each reports a case in which the patients seemed most 
comfortable while lying on the right side (Monthly Jour, of Med. Sci.), 
while, on the other hand, Professor White, of Buffalo (Buf. Med. Jour., 
1855), and Dr. Jas. Carson (Amer. Jour, of Med. Sci., 1857), report cases 
in which position on the right side failed to produce any alleviation of 
symptoms. Other similar observations might be cited, but enough have 
been mentioned to show that no one position should be recommended for 
cyanotic patients. Some obtain most relief by lying on the back, others 
on the right side, others on the left, some when on the hands and knees, 
some when reclining on either side indifferently, while, finally, others suffer 
least when erect. 

There was a time when the paroxysms were treated by venesection, 
but depletion has long since been abandoned. Physicians now rely on 
stimulants, antispasmodics, friction to the chest, and mustard pediluvia, 
to relieve the urgent symptoms, although this treatment is but partially 
successful. It is probable that of all internal remedies digitalis is the 
most useful, from the fact that it is an efficient heart tonic, and more than 
any other medicine gives strength and equality to the heart beats. In the 
cities where oxygen gas can be procured for daily inhalation, it seems not 
improbable that the urgent symptoms might in some instances be partially 
relieved by the use of this agent. 



SECTION V. 
SKIN DISEASES. 



CHAPTER I. 

ERYTHEMATOUS DISEASES. 

Under this head are included erythema, roseola, and urticaria. They 
consist in an active congestion, inflammatory it is believed, of the skin, 
which soon declines, with or without slight furfuraceous desquamation. 
The color of the affected cuticle is bright-red in erythema, rosy in roseola, 
and pale-red in urticaria. Febrile symptoms often precede for a few 
hours the occurrence of the eruption, and abate as it appears. 

Erythema. 

The eruption of erythema occurs in patches of different sizes, the largest 
ordinarily not exceeding four or five inches in length, and most of them 
have considerably smaller dimensions, their margins being in some 
instances diffused, and in others circumscribed and well defined. The 
patches are slightly swollen from engorgement of the capiWaries of the 
skin and slight serous effusion, and are accompanied by a sensation of 
heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathic form is sub- 
divided into erythema simplex, intertrigo, and lseve. Erythema simplex 
is produced by external agencies of an irritating nature, as heat, cold, 
friction, chemical and mechanical irritants, applied to the skin. A com- 
mon example of this form of the disease is the efflorescence about the 
anus in cases of infantile diarrhoea due to acidity of the evacuations. 
Erythema intertrigo is produced by the friction of opposing surfaces of 
the skin, and it therefore occurs mainly in the folds of the. neck, about 
the groins, and behind the ears. This inflammation is sometimes slight, 
disappearing in two or three days with proper treatment ; in other cases 
the epidermis becomes denuded, the surface is tender and moist, and even 
superficial excoriations occur. In severe cases the ulcers extend more 
deeply and give rise to considerable purulent discharge, the skin and even 
subcutaneous connective tissue being more or less infiltrated and indu- 



ERYTHEMA. 731 

rated. The confinement of the perspiration, and the moisture, which is 
exuded between the folds of the skin, increase the inflammation. The 
effused liquid does not in ordinary cases stiffen linen, as in eczema. Ery- 
thema lseve is the name applied to the inflammatory hyperemia of the 
skin, which often occurs over oedematous parts. Its most common seat is 
about the ankles and upon the legs. In children it is most frequently 
observed in the oedema which results from scarlatinous nephritis and from 
heart disease. 

Symptomatic erythema, which results from a general or constitutional 
cause of a pyrexial character, has several subdivisions. The simplest and 
mildest form of it is erythema fugax, which comes and goes quickly. 
The erythema which occurs upon the features in acute meningitis is a 
typical example. It is common in various inflammatory and febrile af- 
fections. If the erythematous patch is circular, with normal skin in its 
centre, it is sometimes designated erythema circinatum, and, if the margin 
is well defined, marginatum. Erythema papulatum, tuberculatum, and 
nodosum are applied to the same form of the disease, one or the other 
term being employed according to the stage or size of the eruption. In 
erythema papulatum the eruption begins as small red spots, which soon 
become papular, and attain a size varying from that of a pin's head to a 
split pea. It occurs especially on the neck, breast, arm, and back of the 
hand, and fades away, with a slight desquamation, in about three weeks. 
In erythema tuberculatum and nodosum the eruptions have a greater 
diameter, and are usually more prominent. In the latter variety they 
often have a diameter of two or more inches, and occur most frequently 
upon the anterior aspect of the leg. These three forms of erythema, 
which might be described as one, occur chiefly in young people. Ery- 
thema tuberculatum is most common in servants, especially those recently 
from the country. The tumefaction is due to the effusion of serum in the 
corium, and, when the eruption has considerable prominence, also in the 
subcutaneous connective tissue. The color is at first a bright-red, then 
dark-red or purple, and it fades away like the discoloration of a bruise 
as the eruption declines. Rheumatism is often and diarrhoea occasionally 
associated with these forms of erythema, and rheumatic pains are occa- 
sionally present, as well as more or less febrile movement. 

Prognosis. — This as regards the erythema is always good. An unfa- 
vorable result in any case is due to cachexia, or some coexisting disease. 
The duration of the milder cases is only a few hours, while those of a 
more severe type, as erythema nodosum, last two or three weeks. 

Diagnosis — The ordinary forms of erythema are distinguished from 
erysipelas, by the absence of any very decided burning pain, and tumefac- 
tion of the integument, and tendency to spread, and by less marked con- 
stitutional symptoms. In those cases of erythema in which there is infil- 
tration and swelling of the skin and subcutaneous connective tissue, the 



732 ERYTHEMA. 

patches are distinguished from those of erysipelas by being multiple, of 
smaller she, less hot and painful, not extending, and presenting as they 
disappear the phenomena of a bruise. In urticaria the wheals that come 
and go suddenly with a peculiar stinging sensation, and the irritability of 
the skin in consequence of which these wheals are produced by slight 
friction, differ so much from the symptoms and appearances of erythema 
that the differential diagnosis of the two is easy. In roseola the eruption 
ordinarily occurs over a large part, if not the entire surface, in points and 
small patches with healthy skin between, and presenting a rosy instead of a 
bright-red color, characters which sufficiently distinguish it from erythema. 
Erythema when extensive is sometimes mistaken for the scarlatinous 
eruption, but the redness of the fauces, graver constitutional symptoms, 
vomiting, persistence of the eruption, etc., serve to distinguish the latter 
from the former affection. In cases of doubt it is proper to defer the diag- 
nosis for a day or two, when if the rash is erythematous it will fade. Ery- 
thema sometimes occurs in the initial stage of variola, when, on account of 
the grave general symptoms, it may be mistaken for scarlatina. I have 
more than once known this mistake to be made in the hurried visit of the 
physician. A more careful examination would prevent this error. There 
is little danger of confounding erythema with measles, or the various papu- 
lar, vesicular, or pustular skin diseases. 

Treatment Erythema fugax requires no special treatment, unless 

occasional dusting the surface with lycopodium or powdered starch. Those 
forms of erythema which are due to mechanical or chemical irritants soon 
disappear when the cause is removed. In erythema around the anus, pro- 
duced by the irritation of the urinary and alvine evacuations, the diaper 
should be changed as soon as soiled, and if the stools are frequent and acid, 
the alkaline treatment proper for the diarrhoea is useful also for the ery- 
thema. In inflammation from this cause as well as in erythema intertrigo, 
the following prescriptions will be found beneficial : — 

R:. Pulv. zinc, oxid., 

Lycopodii, aa equal parts. Misce. 
To be frequently dusted upon inflamed surface. It is better to apply vaseline 
first, and dust upon this. 

R. Zinci oxid., gij ; 
Glycerinse, gij ; 
Liq. plumb, subacetatis, 5i ss 5 
Aquae calcis, t ^vj to viij. Misce. 

In obstinate cases a weak solution of nitrate of silver, sulphate of cop 
per, or better, as it does not stain the linen, sulphate of zinc, will frequently 
be followed by immediate improvement. 

fy. Zinci sulphat.. gr. vj ; 
Grlycerinae, ^ij ; 
Aq. rosse, §iv. Misce. 
To be constantly applied between the folds of the skin on linen. 



ROSEOLA. 733 

Chlorate of potash, internally, to correct the acidity of the transpiration 
from the skin in protracted and obstinate cases, and in certain instances 
cod-liver oil and the syrup of iodide of iron, are called for. If the derange- 
ment of the system upon which the erythema depends appear to be of a 
rheumatic character, colchicum or alkalies may be required. Erythema 
papulatum, tuberculatum, and nodosum occur most frequently in reduced 
states of the system, and therefore need tonics. 

Roseola. 

The term roseola is applied to rose-colored spots or patches of greater or 
less extent, accompanied by a degree of febrile reaction, and often by red- 
ness, with little or no swelling of the faucial surface. It is attended by a 
sensation of warmth and slight itching. The following groups and sub- 
divisions embrace the recognized varieties of this disease : — 

Roseola. 
Idiopathic. Symptomatic. 

Infantilis. Variolosa. 

./Estiva. Vaccinia. 

Autumnalis. Miliaris. 

Annulata. Rheumatica. 

Punctata. Arthritica. 

Cholerica. 

Febris continuee. 

Syphilitica. 

The color of the eruption gradually fades from a rose-red to a duller 
hue, and often disappears in two or three days. In other instances the 
eruption lasts a week or more. Roseola may occur in any season, but it 
is most common, especially the idiopathic form, in the warm months. 
Those varieties of the idiopathic disease which are designated infantilis, 
a3stiva, and autumnalis are the most common in early life. They are in 
reality identical, or nearly so, and may be described as one disease. 

Symptoms. — Roseola infantilis, sestiva, or autumnalis may be partial, 
appearing upon the arms and legs, or general. It is often preceded by 
febrile movement, languor, and in those old enough to describe their sen- 
sations, pain in head, back, and limbs. There is great difference, however, 
in different cases as regards the severity of the prodromic symptoms. They 
may be absent or so slight as scarcely to be appreciable. Occasionally 
vomiting, diarrhoea, or other symptoms of derangement of the digestive 
apparatus immediately precede the eruption. 

The eruption of roseola, when general, usually commences upon or about 
the neck and face, and in the course of twenty-four to thirty-six hours 



734 ROSEOLA. 

appears upon the rest of the surface. It bears considerable resemblance 
to that of measles. The patches are irregular in shape, a quarter to half 
an inch in diameter, and, though of a rose color at first, they soon present 
a dusky hue as they begin to fade ; by pressure the redness disappears. 
In the majority of cases the eruption has nearly faded by the fifth day. 
The redness of the faucial surface, together with the itching or tingling, 
disappears with the subsidence of the rash. 

Roseola annulata is a rare disease. It commences with constitutional 
symptoms, which are slight or pretty severe, and which cease when the 
eruption appears. This occurs in the form of red circular spots, which 
enlarge to the diameter of an inch or thereabout and assume the shape of 
rings inclosing healthy skin. The rash fades in a few days, often leaving 
a bruised appearance. The ordinary location of this form of erythema is 
upon the abdomen, and about the thighs. In roseola punctata the eruption 
is of small size, and it occurs upon a large part of the surface. 

Symptomatic roseola, which appears in the course of various diseases, 
need only be alluded to. The diseases in which it is developed are, with 
the exception of syphilis, chiefly of an acute febrile or inflammatory charac- 
ter. This eruption is often really, as stated by Tilbury Fox, a rose- 
colored erythema, but in other instances it presents the typical form and 
appearance of roseola. Thus I have known it to occur about the eighth 
or ninth day of vaccinia in rose-colored spots over the whole surface, and 
producing much anxiety on the part of parents, lest impure virus had been 
employed. 

Causes These are in a measure obscure. The delicacy of the skin in 

infancy and the active cutaneous circulation no doubt predispose to roseola 
and erythema, and hence the frequency of their occurrence in acute febrile 
and inflammatory affections. Summer weather, with the derangements of 
system which it produces, has been in my experience much the most fre- 
quent cause of idiopathic roseola in young children in this city. In cer- 
tain summers, as in that of 1868, a large proportion of the infants have 
been affected by it, and I have been led to consider it a favorable prog- 
nostic sign as regards the diarrhoea! affections which are so common in the 
warm months. 

Prognosis Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from measles, by the absence of 
catarrhal symptoms, a less degree of fever, less uniformity in the size of 
the eruption, and the absence of any history of contagion. Roseola is 
distinguished from erythema by the smaller size of the eruption and its 
rosy or dusky red color. The boundary line, however, between the two 
diseases is not well defined, and certain forms of roseola might be de- 
scribed as erythema. The general but punctiform efflorescence, increase 
of temperature, acceleration of pulse, and the peculiar appearance of the 
tongue and fauces, serve to distinguish scarlet fever from roseola. There 



URTICARIA. 735 

is little clanger of confounding roseola with urticaria, since the wheals of 
the latter appear in no other disease. 

Treatment This is simple. If roseola occur in connection with 

gastro-intestinal derangement or disease, the remedies which relieve the 
latter exert a curative effect upon the former. In all cases the state of the 
system should be inquired into, and any departure from a state of health 
corrected. Roseola needs no farther constitutional treatment. If there is 
itching or tingling of the surface, a lukewarm lotion, containing equal parts 
of liq. amnion, acetat. and mistura camphorse, has been recommended, or 
a lotion containing a drachm of hydrocyanic acid to a pint of an emulsion 
of bitter almonds, used warm. The purpose of such lotions is simply to 
relieve the unpleasant sensation. Cold applications, or others which would 
repel the eruption, should be avoided; such an effect might be injurious. 
In cases of acidity of stomach alkaline remedies are useful, and in certain 
cases tonic treatment is indicated. 

Urticaria. 

The name by which this disease is designated is derived from the term 
urtica, the nettle, the sting of which produces this form of eruption. The 
eruption occurs suddenly in wheals or pomphi, attended by tingling and 
burning, and suddenly disappearing. Urticaria is often accompanied by 
no very decided general symptoms, but in other cases there are febrile 
movement, and lassitude, with perhaps epigastric pain and headache. The 
wheals may occur over the whole body, but more frequently are confined 
to a portion of it. Their shape may be round, oval, irregular, or band- 
like, and their length varies from a few lines to several inches. In one 
affected by urticaria the wheals can be readily produced by scratching or 
rubbing the surface. The eruption is thus clearly described by a recent 
writer : " At first a bright flush appears, the centre of this becomes slightly 
elevated, and pales, hence appears of lighter color ; the tint may be rosy, 
but more generally it is whitish." The margin of the wheal, the diameter 
of which varies, always remains red. This eruption appears to be pro- 
duced by active congestion of the cutaneous capillaries, some serous effu- 
sion, and spasm of the muscular fibres of the skin. The effusion of serum 
in certain localities is quite apparent from the cedema which occurs. The 
subsidence of the eruption is without desquamation. Urticaria is ordi- 
narily an acute disease. It is sometimes chronic in the adult, but rarely 
so in children. Several varieties of it are described by dermatologists, 
according to the cause, appearance, and duration. 

Causes — These are external and internal. Various irritants apart 
from the nettle applied to the surface produce the wheals, as the bites of 
certain insects and sometimes turpentine. The following are the principal 
internal causes, as summarized by Hillier : 1st, profound and sudden men- 



736 PAPULAR DISEASES. 

tal emotion ; 2d, certain articles of diet, as shell fish, pork, sausage, cheese, 
etc. ; 3d, certain medicinal substances, as copaiba, valerian, and turpen- 
tine ; 4th, intestinal worms, though it is probable that these seldom operate 
as a cause ; 5th, uterine ailments, as hysteria. 

Prognosis — Diagnosis — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of the wheals 
and the possibility of producing them by friction serve to distinguish this 
disease from all others. 

Treatment In urticaria due to any recent ingesta of an irritating or 

indigestible character, an emetic of ipecacuanha is useful, followed by a 
saline, and better also alkaline aperient, as Rochelle salts. An aperient 
of this character is useful ordinarily in acute cases, attended by febrile re- 
action. The diet for several days should be simple, and such as is readily 
digested, as fresh beef, bread, or other farinaceous food, and milk. Occa- 
sionally the wheals appear periodically, when a few doses of quinine effect 
a prompt cure. After the above measures have been employed, the sub- 
sequent treatment, whether tonic or otherwise, depends on the condition of 
the patient. Little benefit accrues from local measures. Sponging the 
surface with cool water to which a little vinegar is added relieves, in a 
measure, the heat and tingling of the wheals. 



CHAPTER II. 
PAPULAR DISEASES. 

STROPHULUS. 

The three papulae, namely, lichen, prurigo, and strophulus, which are 
characterized by small and firm elevations upon the skin, occur in chil- 
dren ; but the two former are not common, and, as they do not differ in any 
essential particular from the same diseases in the adult, they will not be 
treated of in this connection. Strophulus, on the other hand, is a disease 
peculiar to children. It is known as the red gum or white gum according 
to its appearance, and also as the tooth rash. This eruption appears 
usually on parts which are exposed, as the face, neck, and extremities, 
the papules being in some patients of the size of, or even smaller than, a 
pin's head, while in other cases they are as large as a millet-seed. 

The varieties of strophulus described by dermatologists are :- — 

S. intertinctus. S. candidus. 

" confertus. " volaticus. 

" albidus. " pruriginosus. 



STROPHULUS. 737 

The following are the characters of these varieties : S. intertinctus, 
papules bright red, and occurring chiefly upon the cheeks, forearm, and 
back of hand ; often intertinctured with blushes of erythema ; it lasts from 
two to four weeks, and is most common in young infants. S. confertus, 
papules numerous, and closely aggregated, paler, continuing longer than 
in strophulus intertinctus, and likely to recur, appearing about the time of 
dentition, and most frequently upon the arm. Sometimes certain of the 
patches become chronic, slowly disappearing, and leaving the skin rough 
and dry. S. volaticus appears usually upon the arms and cheeks in patches 
of about a dozen, fewer or more, papules, which soon disappear. These 
patches reappear at intervals for two or three weeks, and are attended by 
heat and itching, though not intense. S. albidus, so called, should really 
be placed among the diseases of the sebaceous glands, and described under 
another name. It appears in the form of small white elevations as large 
as a pin's head, commonly upon the face and neck, and produced by dis- 
tension of the sebaceous glands with the secreted product. The term 
strophulus candidus is applied to large whitish papules, which appear upon 
the sides of the trunk, shoulders, and arms of infants of one year or there- 
abouts, and disappear in about one week. They are apt to be associated 
with the papules of strophulus confertus. S. pruriginosus is really a form 
of lichen, occurring chiefly over the age of one, and under that of eight or 
nine years. The papules, which are small and discrete, usually appear 
over a large extent of surface, ordinarily upon the back, front of the chest, 
the face and arms, and, as they are scratched from the itching, minute 
dark points of blood collect and dry upon their apices. This form of 
strophulus is more protracted than the others, and, in consequence of the 
irritation produced by the scratching, pustules of ecthyma often occur 
among the papules. The apparent cause of strophulus pruriginosus is a 
mode of life which impoverishes and vitiates the blood, such as uncleanli- 
ness, residence in damp, dark, overheated, and overcrowded apartments. 
Atmospheric heat also operates as a cause, and it is a not infrequent dis- 
ease in the cities during the summer months. 

The various eruptions included under the term strophulus have such 
different anatomical characters, that a proper classification would locate 
some of them in other groups of skin diseases. One form of it, as we have 
seen, is produced by distension of the sebaceous glands ; in other and the 
majority of cases, as appears from the recent observations of Mr. Fox, its 
seat is the sweat glands, and in others still the papillary layer of the skin, 
as in lichen, the papules being produced by an exudation. 

Treatment — Personal cleanliness, with frequent change of linen, and 
daily ablution without the use of soap, should be enjoined. Local irritants, 
which might aggravate or cause the disease, should, so far as practicable, 
be removed. Alkalies in cases of acidity of the primce vice, and occasion- 
ally mild aperients, are required ; the food should be bland, but nutritious, 
47 



738 ECZEMA. 

and if the child is nursing, it may be necessary to attend to the health of 
the wet-nurse. Favorable hygienic conditions important for the successful 
treatment of all forms of strophulus are especially required in strophulus 
pruriginosus. Nutritious diet, fresh air, quinine, iron, cod-liver oil, etc., 
should be prescribed for those affected by it. The following formula is 
recommended for sponging the surface in cases of strophulus : — 

I£. Sodse carbonat., 9j ; 
Glycerin se, 5ij« ; 
Aq. rosse, §vj. Misce. 



CHAPTER III. 

ECZEMA. 

This is one of the most common maladies of the skin. It constituted 
one-third of Devergie's cases, and one-sixth of Hillier's. In the com- 
mencement of the eczematous eruption the skin presents a superficial 
redness, and upon this inflamed area numerous minute and closely aggre- 
gated papules, vesicles, or, more rarely, pustules, soon appear. These are 
very fragile, so that they soon rupture, the epidermis is broken and. de- 
stroyed, and the surface is moistened by an effusion which appears to be 
serum, and cannot be distinguished from it by the microscope. This 
liquid when dry stiffens linen. As it dries thin crusts form, of a light- 
yellow color, in most localities, but thicker, and of a deeper yellow color 
upon the scalp. The crusts consist mainly of pus, epithelial cells, and 
granular matter. 

Anatomy. — Biesiadecki has described the formation of the eczematous 
eruption. According to him the papules are produced from the papillae, 
which increase in size by cell formation in their interior. The connective- 
tissue corpuscles enlarge, and are unusually "rich in fluid," and their 
number increases. Under the microscope spindle-shaped corpuscles are 
observed, filling the papillae, and extending up from them into the rete 
Malpighii, crowding apart the cells of this layer, and reaching and ele- 
vating the epidermis. The epithelial cells in the immediate vicinity of 
the papillae also become swollen. This cell-growth produces the eczema- 
tous papule. 

If the cell formation continues within a papilla, certain of the cells are 
ruptured, and as they are very moist a liquid is effused, which raises the 
epidermis over the summit of the papilla. This produces the eczematous 
vesicle. Occasionally pus mixes with this liquid, and the eruption is then 
vesico-pustular. 



ECZEMA. 739 

In acute eczema the upper part of the true skin is infiltrated and 
swollen, while the lower part is commonly unaffected, except in the most 
severe cases. The older the eczema the greater the extent of the infiltra- 
tion, so that in chronic eczema the Avhole thickness of the skin is more 
apt to be involved than in acute forms of the malady. The discharge of 
the eczematous surface is irritating, and healthy skin, with which it may 
come in contact, is often reddened by it and made eczematous, from its 
irritating effect. This eczema occurring upon a part of the surface which 
is in contact with an opposite surface of sound skin, commonly affects the 
latter, and as Neumann has stated, a nurse, by carrying an infant having 
eczema upon its nates, may contract the same disease upon her arm, 
although there is no contagious principle in this malady. 

Etiology Eczema is often produced by irritating substances applied 

to the skin. Croton oil, certain soaps, the finger nails in scratching, a 
hat, truss, or belt, by pressure may produce it. Those having a tender 
and delicate skin are more liable to it than others. The constitutional 
causes are often obscure. It is sometimes obviously due to indigestion, or 
a diet which disagrees, for we see it occur in nursing infants as a result of 
sickness of the mother. Anaemia and scrofula are occasional causes. 
Among the city poor eczema is common, and many of the children Avho 
have it are scrofulous, but a large proportion show no evidence of struma, 
and in the better classes of society a majority do not. 

Varieties — Symptoms — Course Eczema is sometimes designated 

according to its location as E. faciei, capitis, etc. Another designation, 
which has more scientific value, is according to the form and stage of the 
eruption, by which we have the following recognized varieties, to wit : 
Eczema papillosum, vesiculosum, pustulosum, rubrum, impetiginosum, and 
squamosum. A simpler and still more convenient classification is into 
eczema simplex, rubrum, impetiginosum, and squamosum. 

Eczema of the scalp is common in infancy, occurring as an eczema 
rubrum or impetiginosum. The eczematous exudation mingling with the 
secretion of the sebaceous glands, which are numerous upon the scalp, 
forms a thick yellow crust. It is apt to extend beyond the hairy portion 
to the forehead and around the ears. This extension aids in establishing 
the diagnosis between eczema and certain other cutaneous eruptions of the 
scalp. Eczema of the external ear is sometimes primary, but in other 
instances it is consecutive to that of the scalp, and due to the extension of 
the latter. Its common seat is in the angle behind the ear, and upon the 
lobe of the ear, whence it often extends along the auditory meatus, nar- 
rowing its calibre, and impairing the hearing temporarily, or even for 
years. Eczema upon the forehead commonly occurs in children from ex- 
tension of the eruption from the scalp. The cheeks, lips, and chin are 
often also affected by eczema, which in this situation is commonly eczema 
rubrum, and is attended by redness, swelling, and troublesome itching. 



740 ECZEMA. 

The swollen and red appearance with the crusts and marks produced by 
scratching often greatly disfigure the countenance. In children, when 
eczema occurs upon other parts, it is usually associated with that of. the 
scalp, face, or ears — that in the latter situations being the most severe and 
obstinate. 

Eczema simplex is common in tlie summer months, being produced by 
the heat of the atmosphere, aided perhaps by other causes. The patient 
may appear well, or be somewhat indisposed, having febrile symptoms, and 
soon an erythematous patch of greater or less extent appears, upon which 
a cluster of the characteristic papules or vesicles soon occurs. These break, 
forming slight crusts, which are detached, and the eczema declines, or it 
may continue longer, with successive crops of the eruption. 

In eczema rubrum, since it is a more severe form of the disease, the febrile 
movement and the local symptoms are greater than in the preceding va- 
riety, and the eczematous patch presents the appearance of a more intense 
inflammation. The papules or vesicles are often so minute as to be with 
difficulty recognized. They are soon broken, when they form with the se- 
cretion and exudation from the surface yellowish or brownish-yellow scabs. 
The discharge is more irritating as it is more abundant than in eczema 
simplex, and the adjacent skin is usually more inflamed from its contact. 

Eczema impetiginodes is common in young debilitated children, in whom, 
in consequence of the cachexia, inflammations, of whatever character, are 
apt to be suppurative. This form of eczema presents at first the symptoms 
and features of eczema rubrum, but the transparent liquid of the vesicles 
soon becomes opaque, from the generation and admixture of pus-corpuscles. 
The crusts, which form from the rupture and desiccation of the vesiculo- 
pustular eruptions, are thick and greenish-yellow, and in infants the seba- 
ceous glands, which are involved in the inflammation, pour out an abundant 
secretion, increasing the thickness of the crusts. This form of eczema is 
most common in infancy, and its usual seat is upon the scalp. 

Diagnosis. — Eczema presents in different instances so different an ap- 
pearance that it is not always readily diagnosticated. It will aid in its 
diagnosis to recollect that it is in its nature a catarrh, affecting primarily 
and chiefly the upper portion of the derma and the Malpighian layer, 
and although it may, at present, present a dry or scaly appearance (E. 
squamosum) yet its history will show that there has been a discharge 
or moisture. In a large proportion of cases, the physician is not able to 
detect papules or vesicles, since they are fragile and transient,, breaking in 
the first thirty-six hours, and not reappearing. Still, when they are absent, 
we sometimes observe around the margin of the patch an appearance which 
indicates that they have been there. Their minuteness is occasionally such 
that they may escape notice, on a cursory inspection, when they are present 
and well defined. Acute eczema, affecting a considerable extent of surface, 
is often attended by febrile movement, and might be mistaken for one of 



TREATMENT. 741 

the eruptive fevers, but the absence of certain distinctive appearances, 
which characterize these fevers, and the speedy appearance of the eruption 
and moisture, establish the diagnosis. Eczema can be readily diagnosti- 
cated from ordinary erythema, which is a superficial inflammation without 
moisture. The location of erythema intertrigo serves for its diagnosis, as 
it is evidently produced by the attrition of opposite surfaces of the skin. 
Moreover it lacks the elevated papilla?, and the discharge does not stiffen 
linen like that of eczema. Lichen, when acute, presents some resemblance 
to eczema, but it is dry and papular, the papules, though small, being de- 
tected by the finger as well as sight. The large and irregular phlyctama, 
intense inflammation and oedema, and mode of extension of erysipelas ; 
large, scattered, and non-inflammatory vesicles of sudamina ; scattered and 
acuminate vesicles, without surrounding inflammation, of scabies; are so 
different from the eczematous eruption that the differential diagnosis is 
readily made. Herpes circinatus can be distinguished from eczema by its 
circular shape, larger size, and greater permanence of the vesicles, and the 
delicate, branny scales, which consist rather of epithelial cells than the 
product of exudation as in eczema. 

Treatment. 1 — Every case of eczema should be cured as quickly as pos- 
sible, as we know that there is no danger of any other disease arising from 
too rapid cure of any skin affection, and also know that a long continued 
eczema may not only seriously interfere with the general health of a child 
from the constant irritation and restlessness which it produces, but also that 
from the cutaneous irritation the neighboring lymphatic glands may be- 
come inflamed and undergo a caseous degeneration, which in turn can 
produce a tubercular formation in the lungs or meninges. The treatment 
of eczema is both local and constitutional. Some cases do well with local 
treatment alone, but in the majority internal treatment is of great assist- 
ance, even when we are unable to detect any dyscrasia or special condition 
of the blood or general system. If any special dyscrasia is present, as 
scrofula, etc., then the child must be treated with the appropriate agents for 
this in addition to the means employed against the eczema. No one line 
of treatment is suitable for every case, and therefore a large number of 
remedies have been used and recommended. Among the city poor stru- 
mous cases are common, and cases also in which without any pronounced 
diathetic state the cause is apparently a reduced state of the system from 
innutritious diet and other anti-hygienic conditions. Such cases require 
better diet and a mode of life more in accordance with the sanitary re- 
quirements. On the other hand, I have observed cases of eczema which 
seemed to be produced by a plethoric state of the system in the nursing 
infant, when the milk of the mother or wet-nurse was unusually rich and 

1 I am indebted to Dr. -A. R. Robinson of the Derniatological Society for the 
revision of the pages which relate to the treatment of eczema. J. L. S. 



742 ECZEMA. 

abundant. While, therefore, ill-nourished and weakly children require 
better regimen, with perhaps vegetable and ferruginous tonics, the plethoric 
require reducing treatment, though of a gentle kind. For the latter the 
following prescription will be found useful : — 

R. Pulv. rhei, 3 SS ; 
Sodse bicarb., 5) ; 

Aquse menth. piperita?, §iv. Misce. 
Dose, one teaspoonful three or four times a day for a child of two years of age. 

In such cases, also, an occasional purgative dose of calomel has been 
recommended by some dermatologists. In addition to measures designed 
to meet the special indications of a case, there is one internal remedy, 
arsenic, which has been found of signal benefit, whatever may have been 
the fault of system from which the eruption originated. As I have stated 
in the chapter relating to therapeutics, children tolerate arsenic much 
better than adults do, consequently it can be given to them in larger pro- 
portionate doses. A most useful combination is that of arsenic with alka- 
line diuretics, as the latter exert a marked beneficial influence upon 
eczema, frequently not inferior to that of arsenic. In fact, at the com- 
mencement of an acute eczema, it is better to give the alkaline diuretics 
alone, and, later in the disease, when there is less redness and irritation 
of the skin, to combine the arsenic with them. The dose of the latter is 
to be regulated according to its effect upon the child and also upon the 
eruption. Always give as large a dose as the child will bear well, so as 
to obtain the best results from its action. The following formula is for a 
child one year old : — 

R. Potassse acetatis, 5i ss '■> 

Liq. potassse arsenitis, gtt. xxiv ; 

Spits, etlieris nitrosi, 5ij > 

Syrupi aurantii, 5 V J ; 

Aquae carui, §iij. Misce. 
Dose, one teaspoonful three times a day. 

If the arsenic produce intestinal irritation, paregoric should be added 
to it. 

Local Treatment — This varies according to the condition of the 
skin at the seat of the eruption. In all cases of acute eczema with irrita- 
ble skin, soothing applications must be employed, and not irritating salves. 
The part should not be washed with water, as it irritates and aggravates the 
eruption. When the surface is red, angry looking, and discharging a thin 
watery secretion, lead or alkaline lotions are useful, as the following : — 

R. Liq. plumbi subacet., ^j ; 
Glycerini, 

Aquse, aa ^iv. Misce. 
To be applied two to four times a day with a camel's -hair pencil. 



SCABIES. 743 

One of the most useful applications for the treatment of eczema in chil- 
dren is a salve made of equal parts of vaseline and simple lead plaster. 
If this proportion is too strong for an individual case, it can be made milder 
by increasing the amount of vaseline. It should be applied twice a day 
by spreading it either on linen or waxed paper. Sometimes the oxide of 
zinc ointment answers very well for the early stages of the disease. The 
ointment of the pharmacopoeia is, however, generally too strong, so that it 
may irritate — five grains to the ounce of simple salve being frequently 
strong enough. Sometimes the part is so tender that only a dusting pow- 
der can be used to protect the surface from the air whilst internal treat- 
ment is employed. When the discharge has become thicker and more 
purulent, and forms scabs, the above mentioned ointments are to be used. 
If the scabs are very thick they can be removed by soaking the part with 
oil and washing once with soap and water. In eczema of the scalp, if the 
hair is long it should be cut as short as possible, otherwise a salve cannot 
be applied with any benefit. When the eruption has arrived at that stage 
when almost all discharge has ceased, and the surface is simply hyperremic, 
with more or less branny scales, some tar preparation should be used. 
These remove the last traces of the eruption, and stop the itching which 
is present. 1 They are to be used as long as any itching or trace of the 
disease is present, since, until they both disappear, there is danger of a re 
turn of the eruption to an acute condition. The oil of cade can be used of full 
strength or diluted with alcohol or mixed with cod-liver oil to any desired 
extent. It must be well rubbed into the part, and applied about once a 
day. In eczema rubrum situated in the flexures of the joints, we have 
obtained good results by the constant wearing of a solid rubber bandage 
on the part until cured. If the eczema occupy a large portion of the 
surface of the body, then it is advisable to endeavor to cure the eruption 
by the internal use of the potash and arsenic mixture given above, com- 
bined or not, according to the effect produced, with alkaline or bran baths. 
In cases of intertrigo, either the lead lotion can be used or the part kept 
as dry as possible with lycopodium powder, to which can be added some 
subcarbonate of bismuth. Flannel should on no account be worn next 
the inflamed surface, since woollen material irritates and keeps up the 
eruption. On account of this irritating action it should not be worn next 
the skin after the eruption has disappeared, lest it might cause a return of 
the disease. 

Scabies. 

The diseases of the skin previously considered are non-contagious. 
Scabies, on the other hand, is one of the most contagious diseases by contact. 

1 The Sisters in the New York Foundling Asylum employ the tar soap in these 
cases, with, they state, an almost uniform good result. 



744 



SCABIES. 



It is produced by an animal parasite, known as the itch-mite, or acarus 
scabiei. The inflammation is caused by the female only, which burrows, 
making for itself a canal, or cuniculus, in which its eggs are deposited. 
The male does not burrow, but conceals itself under the scales or crusts 
which result from the inflammation produced by its partner, or it burrows 
only sufficiently to produce a covering and shelter. From observations 
made by Eichstedt, Gudden, and others, the female has been found within 
half an hour after being placed upon the skin to have concealed herself 
in the epidermis, and the burrow which she constructs is arched and 
tortuous, and four or five lines in length, shorter or longer. The acarus 
lias the shape of a tortoise. It can when fully grown be detected by the 
eye as a minute whitish point. The young acarus has six, the mature 
eight, articulated legs, with suckers upon the two anterior pairs, and hairs 



Fig. 26. 



Fig. 27. 



Fig. 28. 





Fig. 29. 









Fig. 26. The itch animalcule, acarus scahiei, viewed upon the hack, showing its flg-ureand the 
arrangement of its spines and filaments. The female, which is somewhat larger than the male, 
has a length of 1-S0th to l-60th of an inch. 

Fig. 27. The foot and last joints of the leg of the itch animalcule. 

Fig. 28. The male itch animalcule, viewed upon the under surface, showing its legs and lobu- 
lated feet. 

Fig. 29. Ova of the itch animalcule. 



on the posterior. The head, which can be elongated or retracted, is pro- 
vided with two jaws. The upper surface is covered with spines directed 
backwards so as to prevent retrogression in the burrow. She leaves be- 
hind her in the cuniculus, as she advances, her moulted skin, excreta, and 
eggs, which hatch on the eleventh day. The mother acarus -is always 
found at the remote end of the burrow, where it can be seen by the un- 
assisted eye as a minute wdiitish or sometimes brownish speck, and from 
which it can be lifted by the point of a needle to which it clings. The 
cuniculi can also be seen by the naked eye, looking, says Niemeyer, like 
the u scars of needle scratches," and containing the young acari in various 
stages of growth. 



TREATMENT. 745 

The acarus by its burrowing produces an irritation and troublesome 
itching, which is the chief cause of the suffering of the patient. At the 
point where the acarus penetrates the cuticle the inflammation gives rise 
to a single, small, and acuminate vesicular or papular eruption, the cuni- 
culus extending away from it. We often find ecthymatous pustules and 
abrasions intermingled with the vesicles, the result of the frequent scratch- 
ing. The itching is most intense, and the acarus most active, at night, 
when the patient is warm in bed. Scabies most frequently appears, espe- 
cially in adults, first upon the hands, between the fingers, where the skin 
is thin, and it extends thence along the forearm, and over the thighs and 
abdomen. In children it not infrequently occurs upon the buttocks, thighs, 
feet, etc., while the hands and forearm escape. 

Diagnosis Correct diagnosis is important, because the treatment 

required is different from that in any other exanthem, and because the 
suspicion of having this disease always renders one solicitous to know the 
exact nature of the eruption. Scabies can be diagnosticated from those 
diseases for* which it might be mistaken by the following characters : its 
occurrence where the cuticle is thin and delicate, as between the fingers, 
along the anterior aspect of the forearm, upon the abdomen, thighs, and 
inside of the feet ; small size, acuminate shape, and isolated position of 
vesicles : the intermingling with the vesicles of other forms of eruption, 
as papules and pustules, and the presence of linear scars and abrasions 
produced by the scratching ; itching most intense at night ; absence of 
fever ; absence of the disease from posterior aspect of body and arms, and 
from head and face. Scabies may be distinguished by the vesicular char- 
acter of the eruption from all other exanthematic affections except eczema, 
sudamina, and herpes. Eczema is most common on the scalp and face, 
where scabies does not occur, and unlike scabies its vesicles are round and 
thickly aggregated in clusters ; in eczema there is a smarting or prickling 
sensation very different from the intense itching of scabies. In herpes 
the vesicles are large, rounded, and in clusters, and attended by a burning 
or pricking sensation, with but little itching. The eruption in sudamina 
is vesicular and discrete, as in scabies, but it is globular, and accompanied 
by no itching or other local symptoms. 

Treatment — As scabies is due to a species of acarus which burrows 
in the epidermis, it can only be treated successfully by measures which 
destroy this animalcule. If it is destroyed, the disease gets well of itself. 
Sulphur has been employed for a long period for this purpose, since sul- 
phurous acid, which is evolved from the sulphur, is destructive to the ani- 
malcule. The unguentum sulphuris, if thoroughly applied, will rarely fail 
to eradicate scabies. The internal use of sulphur aids the external 
treatment, since a portion of the gas which is generated escapes through 
the pores of the skin. The chief objection to the employment of sulphur 
is its exceedingly unpleasant odor, which is noticeable, however disguised 



746 SCABIES. 

by perfume. Sulphur or any other substance employed externally has 
more effect if it is preceded by a bath, which softens the epidermis, and 
therefore favors the entrance of the remedy into the pores of the skin and 
the cuniculi. 

Helmerich's ointment is very effectual in the treatment of scabies. It 
consists of two parts of sulphur, one of carbonate of potash, and eight of 
lard. " M. Hardy afterwards perfected the method, so as radically to cure 
the disease in two hours. He proceeds in the following manner : The 
patient first undergoes a friction of his whole body for half an hour with 
soft soap, in order to cleanse the skin and break up the burrows ; a warm 
bath of an hour's duration follows, during which the skin is thoroughly 
rubbed, in order to complete the destruction of the burrows ; after which 
frictions for half an hour and upon the whole surface are practised with 
Helmerich's ointment. This completes the cure. Out of four hundred 
patients subjected to this treatment, only four returned to the hospital." 
(Stille's Therapeutics, etc., vol. ii. p. 516.) 

M. Albin Gras experimented with different substances, in order to ascer- 
tain their relative destructiveness to the acarus. The following table 
gives some of the results of his experiments : — 

Immersed in pure water the acarus was alive after three hours. 

" saline water the acarus moved freely after three hours. 

" Goulard's solution the acarus lived after one hour. 

" olive, almond, or castor oil the acarus lived more than two hours. 

" lime-water the acarus died in three-fourths of an hour. 

11 vinegar " " twenty minutes. 

alcohol " " " 

" turpentine " " nine " 

" iodide of potassium the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed in 
the same manner as the sulphur ointment. Camphor is also destructive 
to this animalcule, and the linimentum camphorse, thoroughly applied, is 
a good remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, which is so offensive, one of the 
following ointments may be employed, if the patient is fastidious : — 
R. Unguent, hydrarg. ammoniat., ^j ; 
Moschi, gr. ij ; 
01. lavendul., gtt. ij ; 
01. amygdal., gj. Misce. (From Wilson.) 

This should not be used if the scabies is extensive, but the following, 
which is recommended by Bazin, and is said to cure the disease with three 

applications : — 

R. Anthemis pulv., 
Adipis, 
01. olive©, aa gj. Misce. 



TREATMENT. 747 

In cases which have been protracted, and in which ecthymatous and 
other secondary eruptions have occurred, the scabies can ordinarily be 
readily cured, while the other eruptions remain and disappear more 
slowly. A knowledge of this is important, since the sulphur, or other 
ointment employed for the cure of scabies, should be discontinued when 
the itching ceases and vesicles no longer appear, and tonic, or other treat- 
ment appropriate to cure these secondary eruptions, should be employed 
instead. The sulphur ointment continued, after the scabies is cured, does 
harm, as it irritates the cuticle. It is essential in the treatment of scabies 
that the linen be frequently changed. 



INDEX. 



ABDOMEX, its appearance in dis- 
ease,^ 85 
Abdominal organs in tuberculosis, 129 
Abscess, peripharyngeal, 602 

age, cause, 602 

anatomical characters, 603 

symptoms, 603-605 

diagnosis, prognosis, 607 
Acarus scabiei, 744 
Accidents incidental to birth, 62 
Acephalus, 343 

anatomical characters, 344 

symptoms, prognosis, 344 
Ackerman, Dr., case of thoracentesis, 

570 
Acne syphilitica, 148 
Allin, Dr. C. M., statistics of peri- 
pharyngeal abscess, 607 
Angina, 598 
Anencephalus, 343 
Animal heat, 83 

Anstie, Dr., when thoracentesis is re- 
quired, 568 
Aphtha?, 577 
Apnoea neonatorum, 62 

its treatment, 62 
Apoplexy, 363 

Aqueous cancer of infants, 584 
Armor, Prof. Sam'l G., case of ta?nia, 

672 
Arteritis, umbilical, 69 
Artificial feeding of infants, 55 
Asphyxia neonatorum, 62 

its treatment, 62 
Atelectasis, 530 

acquired, 530 

symptoms, 532 

anatomical characters, 532 

treatment, 533 
Atomizer, its use in croup and diph- 
theria, 512 
Atrophy of brain, 346 
Attitude in disease, 77 



BARKER, Prof. Fordyce, on tur 
peth mineral in croup, 511 
Baths, 60 
Belladonna for whooping-cough, 275 



Billard on softening of stomach, 621 
Bigelow, Dr. W. S., reports of cases of 

diphtheria, 221 
Borax for sprue, 583 
Bosley, Dr. Geo. H., preputial adhe- 
sions, 480 
Bouchut on the effects of the emotions 

on the secretion of milk, 39 
Bowditch, Dr., statistics of thoracen- 
tesis, 567 
mode of operating, 569 
Brain, its chemical analysis, 342 

i s growth, 343 
Brain, atrophy of, 346 
Brain, congestion of, 358 
Brain, hypertrophy, 348 

pathological anatomy, 348 
causes, 349 
symptoms, 350 
diagnosis, 352 
prognosis, treatment, 353 
Brain, imperfect, 345 
case, 345 

symptoms, prognosis, 346 
Brain in tuberculosis, 131 

symptoms of cerebral and menin- 
geal tubercles, 133 
Brainard, Prof., treatment of spina bi- 
fida, 486 
Brice's test, 215 

Brodie, Sir Benjamin, on mercurial in- 
unction, 152 
Bromides for pertussis, 277 
Bronchitis, 518 
causes, 518 

anatomical characters, 518 
symptoms, 522 
capillary bronchitis, 523 
chronic bronchitis, 524 
diagnosis, prognosis, 525 
treatment, 526 
Bronchial phthisis, 128 
its symptoms, 135 
Bruit de souffiet at anterior fontanelle, 

97 
Buck, Dr. Albert H., on paracentesis 

of membrana tympani, 187 
Budd, Dr. AVm., on prevention of scarlet 
fever, 190 



750 



INDEX 



Bulbous fingers, 77 

Bulkley, Dr. L. D., on dactylitis syphi- 
litica, 150 
Byrd, Prof., on resuscitation of the new- 



CAMMANN, Dr., treatment of ner- 
vous cough, 572 
Cancrum oris, 584 
Caput succedaneura, 64 
Castor oil as a galactagogue, 47 
Catamenia, its effects on the milk, 39 
Cavities in lungs, 127 
Cephalaematoma, 70 
Cerebral hemorrhage, 363 
Cerebro-spinal fever, 295 

its causes, 296 

sex, age, 300 

symptoms, cases, 301 

mode of commencement, 302 

symptoms pertaining to the nervous 
system, 303 

digestive system, pulse, 306 

temperature, 307 

respiratory system, 309 

cutaneous surface, 309 

nature, 313 

prognosis, 315 

diagnosis, 317 

anatomical characters, 317 

treatment, preventive, 321 
curative, 32 2 
Cerebro-spinal system, its diseases, 341 
Chapman, Dr. E. N., on alcohol as a 

specific for diphtheria, 257 
Cheesy substance a cause of tuberculosis, 

122 
Chicken-pox, 218 
Childhood, 19 
Cholera infantum, 656 

causes, 656 

symptoms, 657 

anatomical characters, 658 

nature, 660 

diagnosis, prognosis, 661 

treatment, 662 
Chorea, 446 

age, cause, 447 

sex, 448 

uterine irritation, 448 

angemia, rheumatism, 449 

fright, irritation, 453 

intestinal irritation, 454 

lesions of brain and spinal cord, 454 

anatomical characters, 455 

symptoms, 456 

prognosis, 458 

diagnosis, 459 

treatment, 459 

regimenal, 459 



Chorea, treatment — 

medicinal, 459 
Church, Dr. A. S., case of tonic con- 
vulsions from dentition, 594 

case of intussusception, 704 
Circulatory system in disease, 80 
Cirrhosis, syphilitic, 150 
Clark, Prof. Alonzo, case of syphilitic 

communication, 214 
Clothing, 60 
Colitis of childhood, 653 
Colostrum, 34 

Condie, Dr. D. F., on erysipelas, 336 
Congenital hydrocephalus, 373 

anatomical characters, 373 

symptoms, 377 

treatment, 379 
Congestion of the brain, 358 

causes, 359 

symptoms, 361 

anatomical characters, 361 

treatment, 362 
Convulsions, 407 

Convulsions, tonic, from dentition, 594 
Convulsions, internal, 437 

causes, 438 

anatomical characters, 440 

symptoms, 440 

case, 442 

diagnosis, 442 

prognosis, mode of death, 443 

treatment, 443, 445 
Cord, spinal, its diseases, 479 

congestion, 480 
Cormack, Sir John Rose, on diphtheria, 

230 
Coryza, 492 

anatomical characters, symptoms, 
493 

prognosis, treatment, 493, 494 
Cotting, Dr. B. E., cases of rotheln, 

191 
Cough, nervous, treatment, 571 
Cranial sinuses, thrombosis of, 354 
Craniotabes, 93 
Cretinism, 349 
Croup, true, 500 
irran, J. W 
scrofula, 117 
Cyanosis, 712 

its literature, 713 

sex, 715 

causes of the malformations, 715 

time of commencement, 717 

symptoms, 718 

prognosis, 722 

mode of death, 723 

modes of compensation, morbid 
anatomy, 725 

etiology, 726 

treatment, 728 



INDEX 



751 



DACTYLITIS syphilitica, 151 
Dalton, Prof. J. C, on effects of 
maternal emotions, 22 
Delafield, Prof. Francis, case of croup, 
505 
case of chorea, 452 
Dentition, 591 

pathological results of, 592 
case, 594 
diagnosis, 594 
treatment, 595 
Dentition, second, 597 
Dentition in rachitis, 97 
Diagnosis of infantile diseases, 75 
Diarrhoea. 625 

non-inflammatory, 625 
causes, 625 

anatomical characters, 627 
symptoms, 626 
prognosis, treatment, 628 
Diet, effects of improper, 2 7 
Digestion, post-mortem, 620 

case, 621 
Digestive apparatus, its diseases, 573 
Digestive system, 84 
Diphtherial 221 

age, incubation, 221, 222 
nature, causes, 223-231 
bacterian theory, 225-228 
facts showing its constitutional na- 
ture, 229, 230 
anatomical characters, 233-244 
Prof. Rindfleisch's views, 234 
symptoms, 244-250 
of invasion, 245 
respiratory apparatus, 246 
diphtheritic croup, 246 
kidneys, 247 
paralysis, 249 
diagnosis, 250 
prognosis, 251 
cause of death in diphtheria, 252 
treatment, 253-257 
stimulants, 257 
IocpI treatment, 259 
general treatment, 257 
diphtheritic croup. 261-263 
preventive measures, 263 
Diphtheritic gastritis, 620 
Diseases of umbilicus, 69 
Donne, M., mode of examining milk, 

50 
Dress of infants, 61 
Dropsy of brain, congenital, 373 

acquired, 380 
Ductus arteriosus, 18 
Ductus venosus, 18 
Dyspepsia, 609 

from colostrum, 34 



ECLAMPSIA, 407 
causes, 408 
premonitory stage, 409 
symptoms, 410 

anatomical characters, 411, 412 
diagnosis, 413 

prognosis, treatment, 414, 415 
Ecthyma, syphilitic, 148 
Eczema, 738 



anatomy, 


738 






etiology, 


varieties 


symptoms, 


course, 


739 






simplex, 


rubrum, 


impetio 


•modes. 


740 








diagnosis, 


740 






treatment 


741 







local treatment, 742 
Electricity as a means of increasing the 

milk, 45 
Elliot, Prof. George T., case of peri- 
pharyngeal abscess, 603 
Emotions, effects of, in pregnancy, 20 

on the milk, 39 
Emphysema in pulmonary tuberculosis, 

127' 
Entero-colitis of infancy, 630 
Enteritis and colitis of childhood, 653 

causes, 653 

symptoms, 653 

diagnosis, prognosis, 654 

treatment, 655 
Elixir adjuvans, 88 
Enuresis, 87 

Erysipelas in mother an objection to lac- 
tation, 32 
Erysipelas, 332 

age, point of commencement. 334 

causes, 334 

symptoms, 337 

prognosis, 338 

duration, 339 

mode of death, 339 

pathological anatomy, 339 

treatment, 340 
Erythema, 730 

prognosis, diagnosis, 731 

treatment, 732 
Ether in spasmodic laryngitis, 502 
Evanson and Maunsell's treatment of 

cancrum oris, 589 
Eye, its appearance in disease, 75 



FACE, its appearance in disease, 75 
Facial paralysis, 473 
Features in disease, 75 
Feeding, artificial, 55-60 
Fever and ague, 281 
Fleming, Dr., on retro- pharyngeal ab- 
scess, 603 



752 



INDEX 



Flint, Prof. A., Jr., on diet of children, 
27 

Flint, Prof. A., Sr., prevention of pit- 
ting in smallpox, 206 

Foetus, effect on it of maternal emotions, 
22 

Fracture, rachitic, 96 

Fungus, umbilical, 71 



GANGRENE of the mouth, 584 
anatomical characters, 584 

age, causes, 585 

symptoms, 586 

diagnosis, 587 

prognosis, 588 

treatment, 589 
Galactagogues, 44 
Galactorrhea, 42 
Gas, intestinal, in disease, 84 
Gastritis, 615 

cause, 616 

age, 6] 6 

symptoms, 617 

anatomical characters, 618 

diagnosis, prognosis, 619 

treatment, 619 
Gastritis, follicular, 620 

diphtheritic, 620 
Gastro-intestinal hemorrhage, 682 
Gastric softening, 620 
Gee, Dr. Samuel, on state of spleen in 

hereditary syphilis, 149 
Gelatinous softening, 621 
Glands, treatment of, enlarged, 117 
Glottis, spasm of, 438 
Goat's milk, 56 
Granulations, umbilical, 71 
Green, Dr. Caleb, on rotheln, 191 
Grease in the horse, its relation to vac- 
cinia, 210 
Gummy tumors, 149 



HEMORRHAGE, gastro-intestinal, 
682 
Hemorrhage from umbilicus, 71 
Hemorrhage, intra-cranial, 363 
causes, 363 

anatomical characters, 364 
cerebral, 366 
symptoms, 367 
capillary form, 369 
meningeal, 370 
diagnosis, 371 
prognosis, treatment. 372 
Hammond, Prof. Wm. A., on treatment 

of infantile paralysis, 472 
Hassel, Dr., on preparation of Liebig's 

food, 59 
Hawley, James S., on Liebig's food, 59 



Head, its appearance in disease, 75 
Heat, animal, 83 

Heitzmann, Dr., investigations relating 
to the diphtheritic pseudo-membrane, 
235 
Hewitt, Dr. Graily, 609 
Hillier, Dr., on chronic heart murmurs, 

446 
Homans, Dr., Sr., cases of rotheln, 191 
Hooping-cough, 264 

age, causes, 265 

jDathological anatomy, 266 

symptoms, 267 

periods, first, 267 
second, 267 
third, 268 

complications, 269 

convulsions, 269 

bronchitis, 270 

pneumonia, 270 

emphysema, 271 

diagnosis, 273 

prognosis, 274 

treatment, 275 
Holgate, Dr. Thomas H., on preputial 

adhesions, 480 
Hutchinson, Mr. J., on development of 

teeth, 151 
Hughes, Dr., on chorea, 453 
Hydrocephalus, congenital, 373 

anatomical characters, 373 

symptoms, 377 

diagnosis, prognosis, treatment, 379 
Hydrocephalus, acquired, 380 

causes, 380 

anatomical characters, 381 

symptoms, prognosis, 382 

treatment, 382 
Hydrocephalus, spurious, 402 

anatomical characters, 402 

symptoms, 403 

cases, 404 

diagnosis, prognosis, treatment, 
406, 407 
Hypertrophy of brain, 348 

pathological anatomy, 348 

causes, 349 

symptoms, 350 

diagnosis, 352 

prognosis, 353 

treatment, 353 



ICTERUS of the new born, 75 
Impetigo, syphilitic, 148 
Imperfect brain, 345 
symptoms, 346 
prognosis, 346 
Indigestion, 609 
causes, 610 
symptoms, 611 



INDEX, 



Indigestion — 

prognosis, 612 
treatment, 612, 613 
acute indigestion, 613 
chronic, 613 
use of pepsin, 614 
Indigestion from colostrum, 35 
Infancy, 1 7 

Infantile diseases, their diagnosis, 74 
Infantile mortality, its causes, 24 
Infectious diseases, a cause of the great 

mortality of children, 26, 27 
Inflammation, intestinal, 630 
causes, 632 

atmospheric, 632 
dietetic, 633 
dentition, 634 
age, 635 

intestinal, of infancy, 630 
symptoms, 636 
anatomical characters, 639 
diagnosis, 645 
prognosis, treatment, 645 
regimenal, 645 
medicinal, 648 
Inflation, in treatment of intussuscep- 
tion, 705 
Intermittent fever in pregnancy, 20 
Intermittent fever, 2s 1 
incubation, 282 
symptoms, 283 
treatment, 285 
Internal convulsions, 43 7 
Internal catarrh of infants, 630 
causes, 632 
age, 635 
symptoms, 636 
anatomical characters, 639 
diagnosis, prognosis, 645 
treatment, regimenal, 645 
medicinal, 648 
enemata, 650 
external, 652 
Intestinal worms, 664 

ascaris lumbricoides, 664 
tape- worm, 668 
oxyuris vermicularis, 6QQ 
tasnia solium, 668 
trichocephalus dispar, 6 71 
taenia saginata, 669 
taenia elliptica, 670 
bothriocephalus latus, 670 
causes, 673 

symptoms of ascaris lumbricoides, 
674 
of oxyuris vermicularis, 675 
of the tape-worm, 675 
diagnosis, prognosis, treatment, 676 
Intestines, inflammation, 630 
Intestines, the seat of tubercle, 130 
Itch mite. 744 
48 



Intussusception, 687 

without symptoms, 688 
with symptoms, 688 

previous health, 688 

causes, 689 

age, 690 

seat and pathological anatomy, 
690 
in small intestine, 691 
cases, 691-694 
in large intestine, 694 
symptoms, 697 
diagnosis, duration, 699 
prognosis, 700 
mode of death, 702 
treatment, 703-710 



JACKSON, Dr. James, on second 
dentition, 598 
Jacobi, Dr. A., weight of parotid glands. 
57 
statistics of tracheotomy, 514 
Jacobi, Dr. Mary P., on infantile pa- 
ralysis, 468 
Jaundice, a cause of hemorrhage, 73 

in the newborn, 75 
Jenkins, Dr. J. Foster, on umbilical 

hemorrhage, 70 
Jenner, Dr. Edward, introduction of 

vaccination, 209 
Jenner, Sir William, heart murmurs in 

chorea, 446 
Jesty, Benjamin, the first vaccinator, 
208 



KEKMES mineral a cause of gastri- 
tis, 618 
Kidneys, inflammation of, in scarlet 

fever, 173 
Kidneys in diphtheria, 247 
Kilda, St., tetanus in, 421 
Knapp, Prof., cases of cerebro-spinal 

fever, 312 
Krackowizer, Dr. Ernst, statistics of 

tracheotomy, 513 



LACTATIOX, mode of determining 
the capability for, 29 
hindrances to, 29 

depression of nipple, fissured nip- 
ple, 30 
tuberculosis, 31 
syphilis, inflammations, 32 
erysipelas, 33 

facts and rules in reference to, 34 
colostrum, 35 
igo, 17 
Laparotomy, 709 



754 



INDEX 



Laryngitis, catarrhal, 495 

symptoms, 496 

anatomical characters, 497 

treatment, 498 
Laryngitis, spasmodic, 498 

causes, 498 

symptoms, 499 

anatomical characters, 500 

diagnosis, 500 

prognosis, treatment, 501 
Laryngitis, pseudo-membranous, 504 

causes, 504 

anatomical characters, 504 

symptoms, 507 

pathological characters, 509 

diagnosis, prognosis, 510 

treatment, 510, 511 

tracheotomy, 514 
Laryngitis, tubercular, 124 
Laryngitis, stridulous, 437 
Learning, Dr. J. R., case of erysipelas, 

335 
Lebert, M., on structure of gummy tu- 
mors, 149 
Liebig's food, 58 

Limbs, their appearance in disease, 75 
Liver in syphilis, 149 
Livingston, Dr. W. C, case of peri- 
pharyngeal abscess, 607 
Livingston, Dr. R. R., on treatment of 
spasmodic croup, 502 



MALARIAL fever, 281 
Malformations a cause of death, 
24 
Maternal emotions, effects upon the 

foetus, 22 
Mayer, Dr. , observations on the acidity 

of cows' milk, 37 
Measles, 154 

symptoms, 154 

complications, 157 

complications by bronchitis and 

broncho-pneumonia, 157 
by entero-colitis, 158 
by croup and diphtheria, 159 
by gangrene, 159 
anatomical characters, 160 
nature, 160 
diagnosis, 1 60 
prognosis, treatment, 161 
Meconium, 18 
Meningeal hemorrhage, 363 
Meningitis, cerebro-spinal, 295 
Meningitis, simple and tubercular, 383 
age, pathological anatomy, 385 
anatomical characters, 389 
causes, 390 
premonitory stage, 391 



Meningitis — 

symptoms, 392 

diagnosis, 397 

prognosis, 398 

treatment, 399 
Meningitis, spurious, 402 
Microcephalus, 347 
Milk, human, its composition, 36 

its modifications from diet, 36 

changes in composition of cow's 
milk from the food, 37 

its modification from retention in 
the breast, 38 

its modification by age and mental 
impressions, 38 

its modification by the catamenia 
and pregnancy, 39 

quantity required by infant, 41 

difference as regards quantity and 
quality of, 41 

scantiness of, 42 

modes of increasing, 44 

examination of, 50 

vibriones, 51 

composition of, 55 
Minchon's mode of examining milk, 

50 
Minot, Dr. Francis, on umbilical he- 
morrhage, 72 
Morbilli, 154 
Mollities ossium, 89 
Mortality of early life, 24 
Mother, care of, in pregnancy, 19 
Mouth, gangrene of, 584 
Movements in disease, 7 7 
Muguet, 579 
Mumps, 278 



NAVEL, its inflammation, 69 
Necrosis, infantile, 584 
Nephritis in scarlet fever, 173 
Nervous cough, 571 
treatment, 571 
Nervous system in disease, 86 
Nipples, depressed, or excoriated, hin- 
drances to lactation, 30 
Noma, 584 

Noyes, Prof. H. D., on the use of oph- 
thalmoscope, 341 



fTTISOPHAGITIS, symptoms, 608 
VXj anatomical characters, 608 

treatment, 609 
Oidium albicans, 580 
Ogle, Dr., on chorea, 454 
Ophthalmia neonatorum, 65 \ 

its treatment, 67 
Ophthalmoscope in diseases of the brain, 
341 



INDEX. 



I 00 



Osteo-malacia, 90 

Otitis, scrofulous, 110 
Otorrhoea, 176 



PA IX, a symptom of disease, 83 
Papular diseases, 736 
Paracentesis thoracis, 575 
Paralysis, facial, causes, 4 73 

symptoms, prognosis, treatment, 

* 474 
Paralysis, infantile, 462 

case, 463 

symptoms, 465 

prognosis, progress, etiology, 46 7 

anatomical characters, prognosis, 
471 

treatment, 472 
Paralysis with pseudo-hypertrophy, 475 

anatomical characters, 477 

causes, prognosis, treatment, 478 
Paralysis from tubercles in encephalon, 

134 
Parker, Prof. Willard, case of peri- 
pharyngeal abscess, 606 
Parker, E. H., treatment of intestinal 

catarrh, 648 
Parotiditis, 278 

nature, 279 

diagnosis, 280 

treatment, 280 
Peaslee, Prof. Edmund R., treatment 

of croup, 513 
Peacock, Dr., on growth of the brain, 343 
Pemphigus, syphilitic, 148 
Pepsin in indigestion, 614 
Peritoneal tuberculosis, 129 
Pertussis, 264 
Peri-pharyngeal abscess, 602 

age, causes, 602 

anatomical characters, symptoms, 
603 

prognosis, treatment, 607 
Pharyngitis, catarrhal, 598 

anatomical characters, 598 

causes, symptoms, 599 

diagnosis, treatment, 600, 601 
Phlebitis, 354 
Phthisis, 120 
Pleuritis, 549 

causes, 551 

cases, 554 

anatomical characters, 554 

symptoms, 556 

physical signs, auscultation, 558 

percussion, 560 

inspection, mensuration, 560 

diagnosis, 562 

prognosis, 564 

treatment, 564 

thoracentesis, 566 



Pneumonitis, 534 

causes, 535 

anatomical characters, 536 

croupous, 53 7 

catarrhal, 538 

cheesy, 540 

symptoms, 541 

physical signs, 544 

diagnosis, 545 

prognosis, treatment, 556 
Pneumonitis, tubercular, 122 
Post-mortem digestion, 620 
Post, Prof. Altred C, case of peri-pha- 
ryngeal abscess, 606 
Pomeroy, Dr. O. D., on paracentesis 

of membrana tympani, 188 
Poore, Dr., on pseudo-hypertrophic 

paralysis, 475 
Pregnancy, its effects on the milk, 39 
Preputial adhesions, 480 
Pulmonary cavities, 127 
Pulse in health, 81 

after excitement, 82 

in disease, 79 
Pus, retained, a cause of tubercles, 122 



RACHITIS, 89 
age, 89 
causes, 90 

anatomical characters, 91 
stages, 1st, 91 
2d, 92 
3d, 95 
craniotabes, 93 
deforaiities, 94 
reconstruction, 95 
rachitic fracture, 96 
symptoms, 98 
modifications, 99 

diagnosis, prognosis, treatment, 
100, 101 
RadclifFe, Mr., on treatment of chorea, 

458 
Remittent fever, 286 
symptoms, 287 
diagnosis, treatment, 28 7 
Reid, Dr., observations during the epi- 
demic of rotheln in X. Y. city, 
195 
Respiration in health, 79 

in disease, 79 
Respiratory system in disease, 78 
Retro- pharyngeal abscess, 602 
Reynolds, Dr. J. B., case of diphtheria, 

250 
Rheumatism, acute, 326 
causes, symptoms, 327 
duration, prognosis, 329 
diagnosis, treatment, 330 
Ricinis communis, a galactagogue, 47 



756 



INDEX. 



Rickets, 85 
Ridge's food, 60 

Robin, Prof. Charles, on gummy tu- 
mors, 149 
Rokitansky on "hypertrophy of brain, 348 
Roseola, 733 

symptoms, 733 

causes, prognosis, diagnosis, 734 

treatment, 735 
Rotheln, 191 

age, 192 

premonitory stage, 192 

symptoms, 193 

tegumentary system, 193 

(a) skin, 193 

(b) mucous membrane, 193 
pulse, temperature, 194 
respiratory system, 195 
digestive system, 195 
complications, prognosis, 195 
nature, 196 

Routh, effects of variable temperature 

on mortality of infants, 27 
Rubeola, 154 



SAND, Prof. Henry B., case of in- 
tussusception, 710 
Sanne on diphtheria, 257 
Sayrc, Prof. L. A., on a cause of pa- 
ralysis, 480 
Salivary glands, weight of, 59 
Scabies, 743 

diagnosis, treatment, 745 
Scarlet fever, 163 

symptoms, regular form, 163-165 

irregular form, 166 
malignant form, 168 
complications, 168 
convulsions, 168 
diphtheria. 169 
gangrene, 169 
entero-colitis, 170 
rheumatism, 170 
pericarditis and pleuritis, 171 
sequelae, 172 
nephritis, 173 
otorrhoea, 175 
anatomical characters, 176 
nature, 176 
diagnosis, 179 
prognosis, 180 
treatment, 181 

by water, 182 
inunction, 183 
of the nephritis, 185 
of the otorrhoea, 188 
prophylaxis, 189 

belladonna as a prophylactic, 189 
prophylactic regulations of the N. 
Y. Board of Health, 190 



Scrofula, 102 

causes, 102 

vaccination a supposed cause, 103, 
104 

anatomical characters, 106 

glandular hyperplasia, 107 

symptoms, 109 

two types, 109 

its relation to tuberculosis, 113 

prognosis, 113 

treatment, 114 

curative, 114 
Seguin, Dr. E. C, on effects of maternal 
emotions, 22 

on infantile paralysis, 468 
Sewell, Dr. John G., case of cerebro- 
spinal fever, 298 
Skene, Prof. Alex. J. C, case of taenia, 

672 
Sodii boras, for sprue, 583 
Smallpox, 198 

Smith, Prof. Stephen, on umbilical he- 
morrhage, 72 
Spasm of the glottis, 442 
Spine, its diseases, 456 
Spina bifida, 483 

diagnosis, 484 

prognosis, treatment, 485 
Spinal cord and membranes, 479 
Spinal cord, its congestion, 480 

anatomical characters, 481 

symptoms, treatment, 481, 482 
Spotted fever, 295 
Sprue, 579 
Stomach affected with tubercles, 129 

congestion, 615 

softening of, 620 

white softening, 621 
Stomatitis, simple, 573 

causes, 573 

symptoms, appearance, 574 

treatment, 574 
Stomatitis, ulcerous, 575 

causes, 575 

symptoms, prognosis, treatment, 
576 
Stomatitis, follicular, 576 

symptoms, prognosis, 576 

diagnosis, treatment, 576, 577 
Stomatitis, aphthous, 57 7 

causes, symptoms, 578 

diagnosis, prognosis, treatment, 
578, 579 
Stools, their character in disease, 85 
Strophulus, 736 

varieties, treatment, 737 
Struma, 102 

Sweezey, Dr. Gilbert A., case of peri- 
pharyngeal abscess, 605 
Syphilis in pregnancy, 20 
( Syphilis, 143 



INDEX. 



757 



Syphilis, etiology, 143 

mode of contagion, 144 

clinical history, 144 

syphilis in the fetus, 145 

time of commencement of symp- 
toms, 145 

color of skin, 145 

coryza, 146 

mucous patches, 14 7 

roseola, 147 

pemphigus, acne, impetigo, ecthy- 
ma, 148 

visceral lesions, 148 

dactylitis syphilitica, 150 

osseous lesions, 149 

state of the teeth, 151 

prognosis, 152 

treatment, 152 



TAYLOR, Dr. R. W., on dactylitis 
syphilitica, 150 
Teething, 591 
Teething in rachitis, 9 7 
Temperature in health, 81 
Temperature, effects of changes on mor- 
tality of infants, 27 
Tetanus infantum, 417 

cases, 418, 419 

period of commencement, 419 

frequency in certain localities, 420 

causes, 422-430 

symptoms, 431 

mode of death, 433 

prognosis, 433 

duration, 434 

fatal cases, 434 
favorable cases, 434 

diagnosis, 434 

preventive treatment, 434 

treatment, 435 
Therapeutics, 87 
Thrombosis in the cranial sinuses, 354 

anatomical characters, 354 

causes, 356 

symptoms, 357 

diagnosis, prognosis, treatment, 358 
Thrush, 579 

anatomical characters, 5 79 

symptoms, causes, 581 

diagnosis, prognosis, 582 

treatment, 582, 583 
Thymic asthma, 437 
Trismus, 417 

Trousseau, symptoms of rachitis, 98 
Trunk, its appearance in disease, 78 
Tuberculosis in mother a hindrance to 

lactation, 31 
Tuberculosis, 120 

etiology, 121 

general anatomical characters, 122 



Tuberculosis — 

anatomical characters in infancy 
and childhood, 123 

in lungs, 124 

yellow tubercles, 125 

tubercular pneumonia, 126 

cavities in lungs, 127 

bronchial phthisis, 127 

abdominal viscera, 129 

stomach and intestines, 130 

symptoms, 131 

encephalon, 133 

bronchial glands, 135 

physical signs, 136 

lungs, 136 

pleura, 138 

stomach and intestines, 139 

diagnosis, 139, 140 

prognosis, 141 

treatment, 142 

prophylactic, 142 
curative, 143 
Typhoid fever, 288 

causes, 288 

anatomical characters, 288, 289 

symptoms, 290 

complications, 292 

diagnosis, 292 

duration, 293 

prognosis, treatment, 294 



UMBILICAL fungus, 71 
hemorrhage, 71 
Umbilical vessels, inflammation of, 69 
Umbilicus, its diseases, 69 

its in 
Urates, 1< 
Uric acid, 18 

Urine, incontinence of, 87 
Urticaria, 735 

causes, 735 

prognosis, diagnosis, treatment, 736 



VACCINIA, 202 
its history, 203 

its appearance, symptoms, 211 

anomalies, complications, sequels, 
212 

erysipelas, 213 

syphilis, 213 

subsequent vaccinations, 214 

its protective power, 215 

revaccination, 216 

selection of virus, 217 
Van Swieten's remedy, 152 
Varicella, 218 

symptoms, 218 

diagnosis, 219 

prognosis, 220 



758 



INDEX. 



Variola, varioloid, 198 

incubative period, 198 

stage of invasion, 198 

stage of eruption, 199 

stage of desiccation, 201 

mode of death, 202 

anatomical characters, 203 

complications, 204 

prognosis, 204 

diagnosis, 205 

treatment, 205 

prevention of pitting, 206 

varioloid, 202 
Vertebral caries, 487 

causes, 487 

symptoms, 489 

diagnosis, prognosis, treatment, 
490 ; 491 
Vibriones in milk, 51 
Villemin, M., on production of tuber- 
cles, 121 
Virus, its selection for vaccination, 217 



Voice in disease, 7 7 
Vomiting as a symptom, 84 



WADE,' Mr., of Birmingham, dis- 
covery of albuminuria in diph- 
theria, 247 
Weaning, 52 

Wet-nurse, selection of, 49 
West on pertussis, 267 
White, Prof. James P., 729 
White softening, 621 
Wilks, Dr., case of syphilis, 149 
Worms, intestinal, 664 
kinds, 665, 666 
causes, 673 
symptoms, 673 
diagnosis, prognosis, treatment, 676 



TTELLOW 



tubercle, 125 



STILLE & MAISCH'S DISPENSATORY— Now Ready. 

THE NATIONALDISPENSATOM: 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS, 

AND USES OF MEDICINES, INCLUDING THOSE RECOGNIZED IN 

THE PHARMACOPOEIAS OF THE UNITED STATES AND 

GREAT BRITAIN. 

By ALFRED STILLE, M.D., LL.D., 

Prof, of Theory and Practice of Med. and of Clinical Med. in the Univ. of Pennsylvania, etc. 

AND 

JOHN M. MAISCH, Ph.D., 

Prof, of Mat. Med. and Bot. in Phil. College of Pharm., Secretary to the Am. Pharm. Association. 

In one very handsome octavo volume of over sixteen hundred closely printed pages, with 
two hundred illustrations ; extra cloth, $6.75 : leather, raised hands, $7.50. 

PREFACE. 

"In tlie rapid progress of modern research, few subjects have of late years 
received greater accessions of facts than the group of sciences connected with ma- 
teria medica and therapeutics. The new resources thus placed at the command of 
the pharmaceutist and physician have seemed to the authors to justify an attempt 
to make, from the advanced standpoint of the present day, a concise hut complete 
statement of all that is of practical importance to both professions — a digest in 
which that which is old and that which is new shall he so brought together as to 
give to the reader, within the most moderate practicable compass, all the details 
in pharmacology, pharmacy, and therapeutics which he is likely to need in his 
daily avocations. In the almost infinite accumulation of material, this has required 
a careful and conscientious sifting to discard that which is obsolete, untrustworthy, 
or comparatively trivial, without impairing the practical completeness of the work. 
That they have wholly accomplished their object the authors do not venture to 
claim ; but they can say that years of constant labor have been devoted to the task 
of producing a work to which the inquirer may refer with the certainty of finding 
everything which experience has stored up as worthy of confidence in the subjects 
embraced within its scope. 

' ' To this end there have been included all crude drugs and chemical and phar- 
maceutical preparations officinal in the Pharmacopoeias of the United States and 
Great Britain, together with the more important medicines of the French Codex 
and German Pharmacopoeia, which are to some extent prescribed here or which 
may serve for comparison with similar articles in the English and American stand- 
ards. Besides these, a large number of drugs which are not recognized by any 
Pharmacopoeia, are often kept in the shops because they are prescribed by physi- 
cians or used in domestic practice. Some of these give promise of future import- 
ance, and in making a selection among this class of remedies, it was deemed best 
not to err on the side of exclusiveness. Not only have many of them been admitted 
as separate articles, but a large number have found place as allied drugs under the 
heading of more important substances. To these allied drugs reference can readily 
be made by means of the Index. 

" The alphabetical order of arrangement has been adopted throughout, as being 
on the whole the most convenient for reference. In this the non-officinal medi- 
cines have been included with the officinal, the latter being distinguished by an 
affix, showing the Pharmacopoeia to which they have been admitted. The title 
of each article is followed by a full synonymy, English, French, and German, 
together with Latin appellatives and popular names, such as are occasionally used 
in prescriptions and standard works, or through which articles may be recognized. 
As all substances have thus their appropriate place in the body of the work, but 



STILLE AND MAISCH'S NATIONAL DISPENSATORY— Continued. 



little is left for the Appendix, in which may be found the leading reagents, tables 
of weights and measures, comparisons of the scales of different hydrometers, 
alcoholometers, and thermometers, etc. 

"In the treatment of the separate articles, detailed botanical descriptions have 
generally been omitted as being of no practical value, but plants yielding drugs 
have been briefly characterized as to their general aspect and habitat, while fuller 
descriptions have been given of those which are native or naturalized, or which 
seemed to require it from the nature of their product. The treatment which drugs 
undergo before they reach the hands of the pharmacist also receives attention, 
because the physical appearance and chemical composition are sometimes influ- 
enced thereby. Especial care has been bestowed upon both the external and the 
structural characteristics of drugs, so that they may be readily identified and dis- 
tinguished from those which resemble them, and, in aid of this object, a limited 
number of illustrations has been introduced representing their outward forms as 
well as their histological appearances revealed by the microscope. Their proxi- 
mate constituents, when of practical interest, have received special attention, and 
the effort has been made to decide between the conflicting statements of which 
these have been the subject. Chemical formulas have been expressed in the new 
notation, together with the molecular weights of the principal chemicals. When- 
ever products can be advantageously prepared by the pharmacist, one or more 
processes have been given and explained as fully as seemed necessary. Attention 
has been drawn to adulterations and impurities, and the means for detecting them 
have been pointed out. The officinal processes for pharmaceutical preparations 
have in most instances been detailed in the language of the Pharmacopoeia, fol- 
lowed, when requisite, by explanatory and critical remarks, and practical observa- 
tions for the guidance of the operator. 

" With regard to Pharmacodynamics, there is presented, for the first time in a 
Dispensatory, a succinct account of the physiological action of medicines. The 
results of experiments are stated as clearly as possible, and occasionally in the 
theoretical language of the day ; but, as a rule, terms have been employed whose 
meaning is not likely to become obsolete or unintelligible. Whenever it seemed 
possible, an attempt to apply the results of physiological experiments to thera- 
peutical uses has been made ; for although the two fields of inquiry may not be so 
organically connected as to render the former a guide to the latter, it is, never- 
theless, true that a scientific explanation of the curative powers of medicines must 
be sought in the results of their experimental operation upon the animal functions. 

11 In treating of Therapeutics, the most trustworthy results of clinical experience 
are concisely set forth, without discussing the grounds on which they rest. This 
method has proved laborious, and has often required a prolonged judicial exami- 
nation to arrive at a conclusion expressed in a few lines. Its object has been to 
spare the reader the labor of a personal investigation, which could only be made 
with facilities which comparatively few possess. 

"Another feature, novel in a Dispensatory, is the Therapeutical Index. Care 
has been taken to render it as complete as possible, in order that the inquirer may 
be enabled to learn by its means all the more important medicines that have been 
employed in the treatment of each disease. Such an Index thus becomes, to some 
extent, a therapeutical classification of medicines, and it is believed must greatly 
enhance, by its suggestiveness, the working value of the book to the practitioner." 

The very thorough manner in which the authors have carried out their plan, 
may be judged from the extent of the Indexes. Thus, the "Index of Materia 
Medica" covers 55 triple-columned pages, and contains about 10,400 references. 
The "Therapeutical Index," which gives under the head of each disease the 
principal remedies recommended for its treatment, occupies 33 double- columned 
pages, and contains about 3750 references. 



HENRY C. LEA— Philadelphia. 



HENEY G. LE^'S 

(LATE LEA & BLANCHARb H) 

CLASSIFIED OATALO GUE 

OF 

MEDICAL AND SUEGICAL PUBLICATIONS. 



In asking the attention of the profession to the works advertised in the following 
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An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- 
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HENRY C. LEA. 

Nos. 706 and 708 Sansom St., Philadelphia, March, 1879. 



ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO 

THE AMERICAN JOURNAL OF THE MEDICAL SCIEXCES. 



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Free of Postage, fo r SIX DOLL AES Per Annum. 

TERMS FOR 1879 
The American Journal of the Medical Sciences and 1 Five Dollars per annum, 
The Medical News and Library, both free of postage, j in advance. 

OR 
The American Journal of the Medical Sciences, published quar- "] Q . n 

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The Medical News and Library, monthly (384 pp. per annum), and \- per annum 
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SEPARATE SUBSCBirTJOJSS TO 

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In commencing the second year of the second half century in the career of the 
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With its attendant periodicals, the --Medical News and Library" and the "Monthly 
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(For The " Obstetrical Journal," see p.. 23.) 



2 Henry 0. Lea's Publications— (Am. Journ. Med. Sciences). 

cost of Srx Dollars per annum. 

The three periodicals thus offered are universally known for their high professional 
standing in their several spheres. 

I. 

THE AMERICAN JOURNAL OF' THE MEDICAL SCIENCES, 

Editkdbt ISAAC HAYS, M.D., and I. MINIS HAYS, M.D., 

is published Quarterly, on the first of January, April, July, and October. Each num- 
ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
ever necessary. It has now been issued regularly for over fifty years, during the 
whole of which time it has been under the control of the present senior editor. Through- 
out this long period, it has maintained its position in the highest rank of medical peri- 
odicals both at home and abroad, and has received the cordial support of the entire 
profession in this country. Among its Collaborators will be found a large number of 
the most distinguished names of the profession in every section of the United States, 
rendering its original department a truly national exponent of American medicine.* 

Following this is the 'Review Department," containing extended and impartial 
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This is followed by the "Quarterly Summary of Improvements and Discoveries 
in the Medical Sciences." classified and arranged under different heads, presenting 
a very complete digest of medical progress abroad as well as at home. 

Thus, during the year 1878, the "Journal" furnished to its subscribers 77 Original 
Communications, 133 Reviews and Bibliographical Notices, and 255 articles in the 
Quarterly Summaries, making a total of Four Hundred and Sixty-five articles 
illustrated with 48 maps and wood engravings, emanating from the best professional 
miuds in America and Europe. 

That the efforts thus made to maintain the high reputation of the "Journal" are 
successful, is shown by the position accorded to it in both America and Europe as a 
leading organ of medical progress: — 

The Philadelphia Medical and Physical Journal 
issued its first number in 1S20, and after a brilliant 
career, was succeeded in 1827 by the American 
Journal of the Medical Sciences, a peiiodical of 
world-wide reputation ; the ablest aud one of the 
oldest periodicals in the world — a journal which has 
an uusullied record. — Gross's History of American 
Med. Literature, 1S76. 



This ia universally acknowledged as the leading 
American Journal, and has been conducted by Dr. 
Hays alone until I 86s), when his sou was associated 
with him. We quite agree with the critic, that this 
journal is second to none in the language, aud cheer- 
fully accord to it the fir.-t place, for nowhere shall 
we find more able and more impartial criticism, and 
nowhere such a rep-'rtory of able original articles 
Indeed, now that the ''Briiish and Foreigu Medic 



Chirurgieal Review" has terminated its career, the 
American Journal stands without a rival. — London 
Med. Times and Gazette, Nov. 24, 1S77. 

The present number of the American Journal is an 
exceedingly good one, and gives every promise of 
maintaining the well-earuedieputai ion. .f the review 
Our venerable contemporary has our best wishes, 
&ad we can only express the hope that it may con- 
tinue its work with as much vigor and excellence for 
tla-e next ififcy years as it has exhibited in the past. 
—London Lancet, Nov. 24, 1877. 



It is universally acknowledged to be the leaciug 
American medical journal, and, in our opinion, is 
second to none in the language — Boston Med. and 
Surg. Journal, Oct. 1S77. . 

This is the medical journal of our country to which 
the American physician abroad will point with the 
greatest sati-faction, as reflecting the state of medical 
culture in his country. For a great mauy years it 
has been the medium through which our ablest writ- 
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tions — Address of L. P. Yandell, M.D., before Inter- 
national Med. Congress, Sept. 1876. 

And that it was specifically included in the award of a medal of merit to the Publisher 
in the Tienna Exhibition in 1873. 

The subscription price of the "American Journal of the Medical Sciences" bus 
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when paid for in advance, the subscriber receives in addition the "Medical News and 
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II. 

THE MEDICAL NEWS AND LIBRARY 

is a monthly periodical of Thirty- two large octavo pages, making 384 pages per 
annum. Its '-Library Department" is devoted to publishing standard works on the 
various branches of medical science, paged separately, so that they can be detached 
for binding, when complete. In this manner subscribers have received, without ex- 
pense, such works as "Watson's Practice," "West on Children," "Malgaigne's 
Surgery," "Stokes on Fever," Gosselin's "Clinical Lectures on Surgery," and 
many other volumes of the highest reputation and usefulness. With July. 1878, was 
commenced the publication of "Lectures on Diseases of the Nervous System," by 
J. M. Charcot, Professor in the Faculty of Medicine of Paris, translated from the 
French bv George Sigerson, M.D., Lecturer on Biology, etc., Catholic Univ. of 

* Communications are invited from gentlemen iD all parts of the eountry. Elaborate articles inserted 
by the Editor are paid for by the Publisher. 



Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 3 

Ireland {see p. 16), which will be continued to completion during 1879. New sub- 
scribers, commencing with Janijary, 1879, can procure the previous portion by a 
remittance of 50 cents, if promptly made. 

The "News Department" of the "Medical News and Library" presents the 
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A new and attractive feature of this will be found in an elaborate series of Original 
American Clinical Lectures, specially contributed to the News by gentlemen of 
the highest reputation in the profession throughout the United States. During 1878 
there have appeared Lectures by 

S. D. Gross, M.D., Prof, of Surgery, Jefferson Med. Coll , Philada. 

T. Gaillard Thomas. M.D., Prof. Obstetrics, &c. Coll. Phys. and Surg., N. Y. 

William Pepper, M.D.. Prof. Clin. Medicine, Univ. of Penna. 

Lewis A. Sayre, M.D., Prof. Orthopaedic Surg., Bellevue Hosp.Med Coll., N.Y. 

Roberts Bartholow, M.D.. Prof. Theory and Practice of Med., Med. Coll. of Ohio. 

T. G. Richardson, M D., Prof. Genl. and Clin. Surg., Univ. of La., New Orleans. 

S. W. Gross. M.D.. Surg, to Philada. Hospital. 

F. Peyre Porcher, M.D., Prof, of Mat. Med. and Clin. Medicine, Med. Coll. of S. C. 

William Goodell, M.D., Prof. Clin. Gynaecology, Univ. of Penna. 

N. S. Davis. M.D., Prof. Prin. and Prac. of Med., Chicago Med. Coll. 

W. H. Tan Buren, M.D., Prof. Surgery, Bellevue Hosp. Med. Coll., N.Y. 
To be followed by others of similar value from 

Austin Flint, M.D., Prof. Prin. and Prac, of Med., Bellevue Hosp. Med. Coll., N.Y 

Fordyce Barker. M.D., Prof. Clin. Midwifery, &c, Bellevue Hosp. Med. Coll., N.Y. 

L. A. Duhring, M.D., Clin. Prof, of Diseases of the Skin, Uuiv. of Penna. 

TheophilusParyin.M.D., Prof. Obstetrics. &c. Coll. Phys. and Surg., Indianapolis 

J. P. White, M D., Prof, of Obstetrics. &c, Univ. of Buffalo. 

John Ashhurst, Jr., M D., Prof, of Clin. Surg., Univ. of Penna. 

I). Warren Brickell, M.D., Prof. Obstetrics. &c, Charity Hosp. Med Coll., N. 0. 

J. Lewis Smith, M.D., Clin. Lee. on Dis. of Chil., Bellevue Hosp. Med. Coll.,' N.Y. 

William F. Norris, M.D., Clin. Prof, of Diseases of the Eye, Univ. of Penna.. 

P. S. Conner, M.D., Prof, of Anat. and Clin. Surgery, Med. Coil, of Ohio, Cin. 

S. Weir Mitchell. M.D., Phys. to the Infirmary for Nervous Diseases. Philada 

J. M. DaCosta, M.D., Prof. Prin. and Prac. of Med., Jeff. Med. Coll., Philada. ' 

Thomas G. Morton', M.D., Surgeon to Penna. Hospital, Philada. 

F.J. Bumstead, M.D., late Prof, of Venereal Dis., Coll. Phys. and Surg., N.Y. 

J. H. Hutchinson, M.D., Physician to Penna. Hospital. 

Christopher Johnson. M.D., Prof, of Surgery, Univ. of Md.. Baltimore. 

William Thomson, M.D., Lecturer on Ophthalmology, Jeff. Med. Coll.. Philada. 

With contributors such as these, representing every portion of the United States 
the publisher feels safe in promising to the subscriber a series of practical lectures 
unsurpassed in variety, interest, and Value. 

As stated above, the subscription price of the " Medical News and Library" is 
One Dollar per annum in advance; and it is furnished without charge to all advance- 
paying subscribers to the "American Journal of the Medical Sciences." 

III. 

THE MONTHLY ABSTRACT OF MEDICAL SCIENCE 

is issued on the first of every month, each number containing forty-eight laro-e octavo 
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and '• News" — a careful condensation of all that is new and important in the medical 
journalism of the world, and all the prominent professional periodicals of both hemi- 
spheres are at the disposal of the Kditors. To show the manner in which this plan 
has been carried out it is sufficient to slate that during the year 1878 it contained 

3d Arthiie.-i on. Anatomy and Pfiysidlrigu. 

i>(i " ••' Jlttti'riu Jledica and Therapeutics. 

230 " " Medicine, 

lit I " " Satf/erj/. 

79 '■ " Midtviferij and Gynaecology. 

1'* " " 31<-dical .Turin pradcn.ee and Toxicology — 

making in all 558 articles in a single year. 

The subscription to the " Monthly Abstract," free of postage, is Two Dollars 
and a Half a year, in advance. 

As stated above, however, it will be supplied in conjunction with the "American 
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in all about Twenty-one Hundred pages per annum, the whole free of postage, for 
Six Dollars a year, in advance. 

In this effort to bring so large an amount of practical information within the reach 
of every member of the profession, the publisher confidently anticipates the friendly 



4 • Henry C. Lea's Publications — (Dictionaries). 

aid of all who are interested in the dissemination of sound medical literature. He 
trusts, especially, that the subscribers to the "American Medical Journal" will call 
the attention of their acquaintances to the advantages thus offered, and that he will 
be sustained in the endeavor to permanently establish medical periodical literature 
on a footing of cheapness never heretofore attempted. 

PKEMIUM FOE OBTAINING NEW SUBSOEIBEES TO THE "JOURNAL." 

Any gentleman who will remit the amount for two subscriptions for 1879, one of 
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6), or of Fothergill's " Antagonism of Medicine," (see p. 17), or of "Browne on 
the Use of the Ophthalmoscope" (seep. 29), or of "Flixt'sEssays on Conservative 
Medicine" (see p. 15), or of "Sturges's Cltnical Medicine" (see p. 14), or of the 
new edition of "Swayne's Obstetric Aphorisms" (see p. 21), or of "Tanner's 
Clinical Manual" (see p. 5), or of "Chambers's Restorative Medicine" (seep. 
18), or of " West on Nervous Disorders of Children'' (see p. 20). 

*#* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
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IggT The safest mode of remittance is by bank check or postal money order, drawn 
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letters. Address, 

HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. 



JJUNGLISON [ROBLEY), M.D., 

^"^ hate Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subject? and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulae for 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
some royaloctavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
(Just Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation. During the ten years which have elapsed since the last revision, the additior s 
to the nomenslature of the medical scienceshave been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
; the volume now contains the matter of at least four ordinary octavos. 

science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
-jompreheusive, and practical while perspicacious. Jt 
#as because Duuglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English languase. In no 
former revision have the alterations and additions been 
so great. More than six thousand new subjects and terms 
nave been added. The chief terms have been set in black 
letter, while the derivatives follow in small caps: an 
arrangement which greatly facilitates reference. We 
may safely confirm the hope ventured by the editor 
: ' that the work, which possesses for him a filial as well 
is an individual interest, will be found worthy a con- 
tinuance of the position so lona: accorded to it as a 
standard authority." — Cincinnati Clinic, Jan. 10, 1874. 
It has the rare merit that it certainly has no rival 
in the English language for accuracy audexteBt ut' 
references. — London Medical Gazette. 



A book well known to our readers, and of which 
every American ought to be proud. When the learned 
i author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison. having assisted his. 
father in the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it. not in the patchwork manner so dear to the 
. heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited — to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task whieh Dr Dunglison has assumed and car- 
ried through, it is only necessary to state thatmore 
than six thousand new subjects have been added in the 
..present edition.— Phila. Med. Times, Jan. 3, 1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technlc.aU «rmf is simply a sine qua non. In a 



Henry C. Lea's Publications — {Manuals). 



A CENTURY OF AMERICAN MEDICINE. 1776-1876. By Doctors B. H. 
-^*- Clarke. H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- 
some 12mo. volume of about 350 pnges : cloth, $2 25. (Just Ready.) 

This work has appeared in the pages of the American Journal of Medical Sciences during the 
year 1876. As a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



TJOBLYN {RICHARD D.), M.D. 

A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
12mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leatHer, $2 00 
It is tho best book of definitions we have, and ought always to be upon the students's table —Southern 
Med. and Surg Journal. 

ffOD WELL (G. F.), F.R.A.S.. &c. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 

istry, Dynamics, Electricity. Heat, Hydrodynamics, Hydrostatics, Light. Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
many illustrations : cloth, $5. 

J^EILL {JOHN), M.D., and OMITH [FRANCIS G.), M.D., 

-^ Prof, of the Institutes of Medicine in the Univ. of Penno. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo . 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4 ; strongly bound in 
leather, with raised bands, $4 75. 



H 



ARTSHORNE {HENRY), M.D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. C.oth, $4 25 ; leather, $5 00. (Lately Issued.) 
We can say with the strictest truth that it is the j dents, but to many others who may desire to refresh 



best work of the kind with which we areacquainted 
It embodies in a condensed form all recent contribu- 
tions to practical medicine, and is therefore useful 
to every basy prac'itioner throughout our country, 
besides being admirably adapted to the use of stu- 
dents of medicine. The" book is faithfully and ably 
executed. — Charleston Med. Journ., April, 1875. 

The work is intended as an aid to the medical stu- 
dent, and as such appears to admirably fulfil its ob- 
ject by itsexcellent arrangement, thefullcompilatiou 
of facts, the perspicuity aud terseness of language, 
and the clear and instructive illustrations in some 
parts of the work. — American Journ. of Pharmacy. 
Philadelphia, July, 1S71. 

The volume will be found useful, not only to 6tu- 



their memories with the smallest possible expendi- 
ture of time. — N. Y. Med. Journal, Sept. 1874. 

The student will find this the most convenient and 
useful book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1S74. 

This is the best book of its kind that we have ever 
examined. It is an honest, accurate, and concise 
compend of medical sciences, as fairly as possible 
representing their present condition. The changes 
and the additions have been so judicious and thorough 
as to render it, so far as it goes, entirely trustworthy. 
If students must have a conspectus, they will be wise 
to procure that of Dr Harts home. — Detroit Rev. of 
Med and Pharm., Aug 1874. 



J UDLOW {J.L.), M.D. 

A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $3 25 ; leather. $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



fTANNER {THOMAS HAWKES), M.D.,ifc. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital 
4c In one neat volume small 12mo., of about 375 pages, cloth, $1 50. 

*;£* On page 4, it will be seen that this work is offered as a premium for procuring new 
iubscribers to the "American Journal of the American Sciences." 



Henry C. Lea's Publications— -(Anatomy), 



QRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. » 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M.D., and Dr. Westmacott. The Dissectionsjointly by the Author and 
Dr. Carter. "With an Introduction on General Anatomy and Development by T. 
Holmes, M.A., Surgeon to St. George'? Hospital. A new American, from the eighth 
enlargec and improved London edition. To which is added " Landmarks, Medical and 
Surgical," by Luther Holden, F.R C.S., author of " Human Osteology," "A Manual 
of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 
522 large and elaborate engravings on wood. Cloth, $6 ; leather, raised bands, $7. 
(Just Ready.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special; feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
vaich will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
che details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
x thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
sssential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Since the appearance of the last American Edition, the work has received three revisions at the 
hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
requisite to maintain its reputation as acomplete and authoritative standard text-book and work 
of reference. Still further to increase its usefulness, there has been appended to it the recent 
work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" 
— which gives in a clear, condensed, and systematic way, all the information by which the prac- 
titioner can determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. No pains have been spared in the typographical execution of 
the volume, which will be found in all respects superior to former issues. Notwithstanding the 
increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
at a price rendering it one of the cheapest works ever offered to the American profession. 

to consult his* books on anatomy. The work is 
simply indispensable, especially this present Amer- 
ican edition.— Va. Med. Monthly, Sept. 1S7P. 

The addition of the receDt work of Mr. Holden, 
as an appendix, renders this the most practical and 
complete treatise available to American students, 
who find in it a comprehensive chapter on minute 
anatomy, about all that can be taught on general 
and special auatomy, while its treatment of each 
region, from a surgical point of viev, in the valu- 
able section by Mr Holden. is all that will be essen- 
tial to them in practice.— Ohio Mtdical Recorder, 
Aug 1S7S. 

It is difficult to speak in moderate terms of this 
new edition of "Gray." It seems to he as nearly 
perfect as it is possible to make a book devoted to 
any branch of medical science. The labors of the 
eminent men who have successively revised the 
eight editions through which it has passed, would 
seem to leave nothing for future editors to do. The 
addition of Holden's "Landmarks" will make it as 
indispensable to the practitioner of medicine and 
surgery as it has been heretofore to the student. As 
regards completeness, ease of reference, utility, 
beauty, aDd cheapness, it has no rival. No stu- 
dent should enter a medical school without it ; no 
physician can afford to have it absent from his 
library. — St. Louis Clin. Record, Sept. 1878. 



'the recent work of Mr Holden, which was no- 
ticed by us on p. 53 of this volume, has been added 
a* au appendix, so that, altogether, this is the moi t 
practical and complete anatomical treatise available 
to American students ana physicians. 'Ihe former 
lluds in it the necessary guide in makiug dissec- 
tions ; a very comprehensive chapter on minute 
anatomy ; and about all that can be taught him on 
general and special anatomy; while the latter, in 
its treatment of each region from a surgical point of 
view, aud in the valuable edition of Mr Holden, 
will find all that will be esseutial to him in his 
practice — New Remed-es, Aug. 1878. 

This work is as near perfection as one could pos- 
sibly or reasonably expect any book intended as a 
text-book or a general reference book on anatomy 
to be. The American publisher deserves the thanks 
of tho profession for appending the recent work of 
Mr. Holdea, "Landmarks, Medical and Sm yical," 
which has already been commended as a separate 
book. 'Ihe latter work— treating of topographical 
anatomy— has become an essential to the library of 
every intelligent practitioner. We know of no 
book that can take its place, wjitten as it is by a 
most distinguished anatomist. It would be simply 
a waste of words to say anything further in praise 
of Gray's Anatomy, the text-book in almost every 
medical college in'this country, and the daily refer 
eiice book of every practitioner who has occasion 



Also for sale separate — 
TTOLDEN {LUTHER), F.R.C.S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 

Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. (Now Ready.) 
The title of this book is very suggestive of its 
practical value, while the perusal of the work itself 
verifies the most extravagant expectations. The 
object of the author has been to collect in compact 
form the landmarks, or surface-marks of the different 



parts of the body, and indicate their relation to the 
ceepev-seated parts. The value of this sort of know- 
ledge to the physician, but especially to the surgeon 
wlo. with anatomical eye, can make the tissues 



transparent before him, is incalculable. The map- 
ping out oi the human body is one which is most in. 
structive to the practical man, and he is enabled, 
after considerable experience, to have landmarks 
of his own; but in the little work before us this 
knowledge is systematized in such an intelligible 
manner as to place it within the reach of all. It is 
one of the most interesting little works we have seen 
for a long time — N. Y. Med. Record, May 11, 1878. 



Kenry C. Lea's Publications— {Anatomy). 



A LLEN (HARRISON), M.D. 

•*-*- Professor of Physiology in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Students of Medicine. With tin 
Introductory Chapter on Histology. ByE. 0. Shakespeare, M D, Ophthalmologist to the 
Phila. Hosp. In one large and handsome quarto volume, with several hundred original 
illustrations on lithographic plates, and numerous wood-cuts in the text. {Preparing.) 
In this elaborate work, which has been in active preparation for several years, the author has 
sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
the practical applications of the science to medicine and surgery. The work thus has claims upon 
the attention of the general practitioner, as well as of the student, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize the significance of all varia- 
tions from normal conditions The marked utility of the object thus sought by the author is 
self-evident, and his long experience and assiduous devotion to its thorough development are a 
sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original dissections, drawn on 
stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
after the manner of "Holden" and "Gray" and in every typographical detail it will be the 
effort of the publisher to render the volume worthy of the very distinguished position which is 
anticipated for it. 

TJLLIS [GEORGE VINER), 

Emeritus Proftssor of Anatomy in University College., London. 

DEMONSTRATIONS IN ANATOiMY; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised London 
Edition. In one very handsome octavo volume of over 700 pages, with 248 illustrations. 
{Nearly Ready.) 
This work has long been known in England as the leading authority on practical anatomy, 
and the favorite guide in the dissecting-room, as is attested by the numerous editions through 
which it has passed. In the last revision, which has just appeared in London, the accomplished 
author has sought to bring it on a level with the most recent advances of science by making the 
necessary changes in his account of the microscopic structure of the different organs, as devel- 
oped by the latest researches in textural anatomy. 

WILSON (ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical Co], 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather, $5 

fJEATH [CHRISTOPHER), F.R.C.S., 

**-*■ Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keek 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia! 
In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth $3 50 • 
leather, $4 00. ' 

&MITH [HENRY H.), M.D., and JJORNER [WILLIAM E.), M.D., 

Prof, of Surgery in the Univ. of Penna. , &c. Late Prof, of Anatomy in the Univ. ofPenna., 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 

T>ELLAMY(E.),F.R.C.S. 

THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 
Book for Students preparing for their Pass Examination. With engravings on wood. In 
one handsome royal 12mo. volume. Cloth, $2 25. {Lately Published.) 

fILELAND [JOHN), M.D., 

^y Professor of Anatomy and Physiology in Queen's College, Galway. 

A DIRECTORY EOR THE DISSECTION OF THE HUMAN BODY. 

In one small volume, royal l2mo. of 182 pages: cloth, $1 25. {Just Issued.) 

CHAFER [EDWARD ALBERT), M.D., 

Assistant Prof e>sor of Physiology in University College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with 
numerous illustrations: cloth, $2 00. {Just Issued.) 



s 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In 2 vols. Svo. , of over 1000 pages, 
with 320 wood cuts ; cloth, $6 00. 



SHARPEY AND QUAIN'S HUMAN ANATOMY. 
Revised, by Joseph Leidt, M.D.,Prof of Anat. 
in Univ. of Penn. In two octavo vols, of about 
1300 pages, with 511 illustration*. Cloth, $6 00. 



8 



Henry C. Lea's Publications- 



(Physiology). 



flARPENTER ( WILLIAM B.), M.D., F.R.S., F.G.S., F.L.S., 

V' Registrar to University of London, etc. 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, 

M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
tions, by Francis G-. Smith, M. D., Professor of the Institutes cf Medicine in the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octaA o volume, ol 1 083 pages, 
withtv opiates and 373 engravings on wood,- cloth, $5 5.0 ; leather. $6 50. {Just Issued.) 
The great work, the crowning labor of the distinguished author, and through which so many 
generations of students haye acquired their knowledge of Physiology, has been almost metamor- 
phosed in the effort to adapt it thoroughly to the requirements of modern science. Since the 
appearance of the last American edition, it has had several revisions at the experienced hand of 
Mr. Power, who has modified and enlarged it so as to introduce all that is important in the 
investigations and discoveries of England, France, and Germany, resulting in an enlargement of 
about one-fourth in the text. The series of illustrations has undergone a like revision, a large 
proportion of the former ones having been rejected, and the total number increased to nearly 
four hundred. The thorough revi?ion which the work has so recently received in England, has 
rendered unnecessary any elaborate additions in this country but the American Editor, Pro- 
fessor Smith, has introduced such matters as his long experience has shown him to be requisite 
for the student. Every care has been taken with the typographical execution, and the work i3 
presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for 
the student and practitioner of medicine — the one in which, as heretofore, especial care is directed 
to show the applications of physiology in the various practical branches of medical science. 
Notwithstanding its very great enlargement, the price has not betn increased, rendering this 
one of the cheapest works now before the profession. 



We have been agreeably surprised to find the vol- 
ume so complete in regard to the structure and func- 
tions of tbe nervous system in all its relations, a 
bubject that, in many respects, is one of the most diffi- 
cult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatise of 
the class to which the one before us belongs. The 
additions by the American editor give to the work as 
it is a considerable value beyond that of the last 
English edition. In conclusion, we can give our cor- 
dial recommendation to the work as it now appears. 
The editors have, with their additions to the only 
work on physiology in our language that, i n the full- 
est sen-e of the word, is the production of a philoso- 
pher as well as a physiologist, brought it up as fully 
as could be expected, if not desired, to the standard 
of our knowledge of its subject at the preeent day. 
It will deservedly maintain the place it ha,s always 
had in the favor of the medical profession. — Journ. 
of Nervous and Mental Disease, April, 1S77. 

"Good wine needs no bush" says the proverb, and 
an old and faithful servant like the " big" Carpenter, as 
carefully brought down as this edition has been by Mr. 
Henry Power, needs little or no commendation by us. 
Such enormous advances have recently been madein our 
physiological knowledge, that what was perfectly new a 
year or two ago. looks now as if it had been a received 
and established fact for years. In this encyclopaedic 
way it is unrivalled. Here, as it seems to us, is the 
great value of the book: one is safe in sending a student 
to it for information on almost any given subject, per- 



fectly certain of the fulness of information it will con- 
vey, and well satisfied of the accuracy with which it will 
there be found stated. — London Med. Times and Gazette, 
Feb. 17, 1877. 

Thusfully are treated the structure and functions of all 
the important organs of the body, while there are chap- 
ters on sleep and somnambulism ; chapterson ethnology , 
a full section on generation, and abundant references to 
the curiosiiies of physiology, as the evolution cf light, 
heat, electricity, etc. In short, this new edition of Car- 
penter is, as we have said at the start, a very encyclo- 
pedia of modern physiology. — The Clinic, Feb. 24, 1877. 

The merits of "Carpenter's Physiology are so widely 
known and appreciated that we need only allude briefly 
to the fact that in thelatest edi'ion will be found a com- 
prehensive embodiment of the results of recent physio- 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition. — N. Y.Med Journal, J an. 1S77 . 

A more thorough work on physiology could not be 
found. In this all the facts discovered by the late re- 
searches are noticed, and neither student nor practi- 
tioner should be without this exhaustive treatise on an 
important elementary branch of medicine. — Atlanta 
Med. and Surg. Journal, Dec. 1876. 



L£IRKES ( WILLIAM SENHOUSE), M.B. 

A MANUAL OP PHYSIOLOGY. Edited by W. Morrant Baker, 

M.D., F.R.C.S. A new American from the eighth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 75. (Lately Issued.) 
Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
presenting within a. narrow compass all that is important for the student. The rapidity with 
which successive editions have followed each other in England has enabled the editor to keep it 
thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
edition, of which the present is a reprint, has a 
the latest accessible exposition of the subject. 

On the whole, there is very little in the book 
whieh either the student or practitioner will not find 



of practical value and consistent with our present 
knowledge of this rapidly changing science ; and we 
hive no hesitation in expressing our opinion that 
this eighth edition is one of the best handbooks on 
physiology which we have in our language. — N. T. 
Med. Record, April 15, 1873. 

The booh is admirably adapted to be placed in 



ppeared so recently that it may be regarded as 
Boston Med. and Surg. 



the hands of students. 
Journ., April 10. 1873. • 

In its enlarged form it is, in our opinion, still the 
best book on physiology, most useful to the student. 
—Phila. Med. Times, Aug. 30, 1873. 

This is undoubtedly the best work for students of 
physiology extant.— Cincinnati Jhed. News, Sept. '73. 



H 



ARTSHORNE {HENRY), M.D., 

Professor of Hygiene, etc , in the Univ. ofPenna. 

HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 
tion, revised. In one royal 12mo. volume, with 220 wood-cutf: cloth, $1 75. (Just Issued.) 



Henry C. Lea's Publications — (Physiology). 



f)ALTON (J. C), 31.D., 

•*~* Professor of Physiology in the College of Physicians and Surgeons, New York, &c. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. [Just Issued.) 

From the Preface to the Sixth Edition. 
In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
new material. 

The additions and alterations in the text, requisite to present concisely the growth of positive 
physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, 
in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 

The new chemical notation and nomenclature are introduced into the present edition, as hav- 
ing now so generally taken the place of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, is also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade scale, 
usually accompanied hy the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
New York, September, 1S75. 
During the past few years several new works on phy-i This popular texi-book on physiology comes to us in 
siology, and new* editions of old works, have appeared, J its sixth edition with the addition of about fifty percent, 
competing for Che favor of the medical student, but none | of new matter, chiefly in the departments of patho- 
will rival this new edition of DaUon. As now enlarged. I logical chemistry and the nervous system, where the 
it will be found also to be. in general, a satisfactory work priucipal advances have been realized. With so tho- 
of reference for the practitioner. — Chicago Med.Joum. routrh revision and additions, that keep the work well 
and Examiner, Jan. 1 876. up to the times, its continued popularity may be confi 

Prof. Dalton has discussed conflicting theories and deati ^ P redicted > notwithstanding the" competition it 
conclusions regarding physiological questions with aj f av ^counter. The publishers work is admirably 
fairness, a fulness, and a conciseness which lend fresh- 1 done -- s <- Louis Med - and ^ r 9- ^'tirn , Dec. 1875 
ness and vigor to the entire book. But his discussions! We heartily welcome this, the sixth edition of this 

admirable text book, than which there are none of equal 
brevity more valuable. It is cordially recommended by 
the Professor of Physiology in the University of Louisi- 
ana, as by all competent teachers in the United States 
and wherever the English language is read, this book 
has been appreciated. The present edition, with its 316 
admirably executed illustrations, has been carefully 
revised and very much enlarged, although its bulk does 
not seem perceptibly increased. — New Orleans Medical 
and Surgical Jmirnal, March, 1876. 

The present edition is very much superior to every 
other, not only in that it brings the subject up to the 
times, but that it drag so more fully and satisfactorily 
than any previous edition. Take it altogether, it remains 
in our humbleopinion. the best text book on physiology 
in any land or language. — The Clinic. Nov. 6, 1875. 
As a whole, we cordially recommend the work as a 

text-book for the student, and as one of the best. 

The Journal of Nervous and Mental Disease. Jan. 1S76. 

Still holds it* position as a masterpiece of lucid writ- 
ing, and is, we believe, on the whole, the best book to 
place in the hands of the student. — London Students' 
Journal. 



have been so guarded by a refusal of admission to those 
speculative arid theoretical explanations, which at best 
exist in the minds of observers themselves as only pro- 
babilities, that none of his readers need be led into 
grave errors while making them a study. — The Medical 
Record, Feb. 19, 1876. 

The revision of this great work has brought it forward 
with the physiological advances of the day. and renders 
it, as it has ever Oeen. the finest work for studenis ex- 
tant. — Nashville Journ. of Med. and Surg., Ja.ii. 1876. 

For clearness and perspicuity. Dalton's Physiology 
?ommended itself to the student years ago. and was a 
pleasant relief from the verbose productions which it 
supplanted. Physiology has. however, made many ad- 
vances since then— and while the style has been pre- 
served intact, the work in the present edition has been 
brought upfullyabreastof the times. The newchemical 
notation and nomenclature have also been introduced 
into the present edition. Notwithstanding the multi- 
plicity of text-books on physiology, this will lose none 
of its old time popularity. The mechanical execution 
of the work is all that could be desired. — Peninsular 
Journal of Medicine, Dec. 1875. 



nUNGLISON {ROBLEY), M.D., 

--t^ Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HITMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 

JTEHMANN (C. G.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
tion by George E. Dat, M.D., F.R.S., &c, edited by R. E. Rogers, M D., Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustration* 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $6 00. 

Df THE SAME AUTHOR. 

MANUAL 0F 4 CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J Cheston Morris, M.D., with an Introductory 

Essay onVital Force, by Professor Samuel Jackson, M.D., of the University of Penn«yl- 

V , a ^l a '*JV th lllusfcrati oae on wood. In one very hardsome octavo volume of 336 pacces, 
eloth, $2 2' . r 



10 



Henry 0. Lisa's Publications— (Chemistry). 



pOWNES {GEORGE), Ph.D. 



A MANUAL OF ELEMENTARY CHEMISTRY ; Theoretical and 

Practical. Revised and corrected by Henry Watts, B. A., F R.S., author of " A Diction- 
ary Of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
trations. A new American, from th» twelfth and enlarged London edition. Edited by 
Robert Bridges, M.D. In one larpe royal 12mo. volume, of over 1000 pages; 
cloth, $2 75 ; leather, $3 25. (Just Ready.) 
Two careful revisions by Mr. Watts, since the appearance of the last American edition of 
'* Fownes," have so enlarged the work that in England it has been divided into two volumes. In 
reprinting it, by the use of a sma'l and exceedingly clear type, cast for the purpose, it has been 
found possible to comprise the whole, without omission, in one volume, not unhandy for study and 
reference. The enlargement of the work has induced the American Editor to confine his additions 
to the narrowest compass, and be has according]} 7 inserted only such discoveries as have been an- 
nounced since the very recent appearance of the work in England, and has added the standards 
in popular use to the Decimal and Centigrade systems employed in the original. 

Among the additions to this edition will be found a very handsome colored plate, representing 
a number of spectra in the spectroscope. Every care has been taken in the typographical execu- 
tion to render the volume worthy in every respect of its high reputation and extended use, and 
though it has been enlarged by more than one hundred and fifty pages, its very moderate price 
will still maintain it as one of the cheapest volumes accessible to the chemical student. 



This work, inorganic and organic, is complete in 
one convenient volume. In its earliest editions it 
was fully up to the latest advancements and theo- 
ries of that time. In its present form, it presents, 
in a remarkably convenient and satisfactory man- 
ner, the principles and leading facts of the chemistry 
of to-day. Concerning the manner in which the 
various subjects are treated, much deserves to be 
said, and mostly, too, in praise of the book. A re- 
view of such a work af Foumes's Chemistry within 
the limits of a book-notice for a medical weekly is 
simply out of the quest ion. — Cincinnati Lancet and 
Clinic, Dec. 14, 1878. 

When we state that, in our opinion, the present 
edition sustains in every respect tie high reputation 
which its predecessors have acquired and enjoyed, 
we express therewith our fall belief in its intrinsic 
value as a text-book and work of reference. — Am. 
Journ. of Pharm., Aug. 1S78. 

The conscientious care which has been bestowed 
upon it by the American and English editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



what formidable magnitude with its more than, a 
thou-and pages, but with less than this no fair repre- 
sentation of chemistry as it now is can be given. The 
type is small but very clear, and the sections are very 
lucidly arranged to facilitate study and reference. — 
Med and Surg. Reporter, Aug 3, 1878. 

The work is too well known to American students 
to need any extended notice; suffice it to say that 
the re vi- ion by the English editor has been faithfully 
done, and that Professor Blidges has added some 
fresh and valuable matter, especially in the inor- 
ganic chemistry. The book has always been a fa 
vorite in this country, and in its new shape bids 
fair to retain all its former pr^stig/e. — Boston Jour, 
of Chemistry, Aug 1878. 

It will be entirely unnecessary for us to make any 
remarks relating to the general character of Powne's 
Manual For over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from time 
to time leave little chance for any wide awake rival to 
step before it. — Canadian Pharm. Jour., Aug. 1878. 

As a manual of chemistry it is without a superior 
in the language. — Md. Med. Jour., Aug. 1S7S. 



^TTFIELD {JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Eighth American edi- 
tion, revised from the Seventh English edition by the author. In one handsome royal 12mo, 
volume of over 700 pages, with illustrations. (In press.) 
A few notices of the previous edition are subjoined. 



It is a valuable work for the busy practitioner, ex- 
cluding as it does everything that would be of inte- 
rest only to the scientific chemist, aud having a com- 
prehensive index which renders after consultation 
easy. That portion devoted to urinalysis and prac- 
tical toxicology, and the tests for impurities in medi- 
cinal preparations, is especially valuable to the 
practising physician. For the student it is desirable, 
for the reason that it is so arranged that he may, 
without an instructor, study the science experiment- 
ally* — Am. Practitioner, March, 1S77. 

An>r having used it as a text-book in the laboratory 
of the PhiladelphiaColIege of Pharmacy during the last 
five years, we can speak from our own experience, and 
testify to its intrinsic value in the instruction of the 



student. The more we have used it, the more we were 
pleased with it. and on the appearance of a new, revised, 
and enlarged edition, we take occasion to again cordi- 
ally recommend it. believing that for the practical in- 
struction of pharmaceutical students in chemistry it 
has no superior in the English language.— Am. Journ. 
of Pharm., Nov. 1876. 

As a compact manual of the general principles of the 
science and their applications in medicine and phar- 
macy, it has no rival, and the frequent and thorough 
revision it receives keeps it in all respects up with the 
times. The American edition, which covers the United 
States Pharmacopoeia, is prepared under the author's 
supervision. — Boston Joumalof Chemistry, Nov. 1876. 



RO WMAN {JOHN E.) , M.D. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- 
ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. 
Z2Y THE SAME AUTHOR. 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. In one 

neat volume, royal ]2mo., pp. 351, with numerous illustrations ; cloth, $2 25. 

KNAPP'S TECHNOLOGY ; or Chemistry Applied to I very handsome octavo volumes, with 500 wood 
the Arts, and to Manufactures. With American engravings, cloth, $6 00. 
additions by Prof. Walter R. Johnson. In two J 



Henry C. Lea's Publications — {Chemistry). 



11 



JOLOXAM (C.L.), 

■*-* Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
tions. Cloth, $4 00; leather, $5 00. (Lately Issued.) 

science as it now stands. We have spoken of the 
workasadmirably adapted to the wants of students ; 
it is quite as well suited to the requirements of prac- 
titioners who wish to review their chemistry, orhave 
occasion to refresh their memories on any point re- 
lating to it. In a word, it is a book to be read by all 
pvho wish to know what is the chemistry of the pre- 
sent day.— American Practitioner ,Nov . 1S73. 



We have in this work a complete and most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Joum., May 28, 1S74. 

The above is the title of a work which we can most 
conscientiously recommend to students of chemistry. 
It is as easy as a work on chemistry could be made, 
at the same time that it preseuts a full account of that 



ffLASSEN (ALEXANDER), ' 

^ Professor in the Royal Polytechnic School, Aix la-Chapelle. 

ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 

notes and additions by Edgar F. Smith, Ph.D., Assist. . Prof, of Chemistry in the 

Towne Scientific School, Univ. of Penna. In one handsome royal 12mo. volume, of 324 

pages, with illustrations; cloth, $2 00. (Just Ready.) 

This little book will supply a wa,nt of a condensed and convenient laboratory guide for the 

student in quantitative analysis. Since its appearance in Germany, two or three years since, 

it has been received throughout the continent as a recognized authority, and its translation 

into French and Russian shows that the author has succeeded in thoroughly fulfilling the object 

at which he aimed. The translator has added such processes and details as seemed requisite to 



adapt the volume more thoroughly to the want 

A small, practical, comprehensive, and intelligible 
guide to practical elementary quantitative analysis, 
and is particularly adapted to the wants of the be- 
ginner with laboratory work. — N. ¥. Med. Record, 
JSlov. 12, 1S78. 

It is probably the best manual of an elementary 



ot the American student. 

nature extant, iDsomuch as its methods are the best. 
It teaches by examples, commencing with single 
determinations, followed by separations, and then 
advancing to the analysis of minerals and such pro- 
ducts as are met with in applied chemistry. It is 
an indispensable book for students in chemistry. — 
Boston Journ. of Chemistry, Oct. 1878. 



fILO WES (FRANK), D.Sc, London. 

^ Senior Science- Waster at the High School, Newcastle-un der Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTIC A L CHEMISTRY 

AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 
English Edition, with about fifty illustrations on wood. In one very handsome royal 
12mo. volume of 372 pages : cloth, $2 50. (Note Ready.) 
It is short, concise, and eminently practical. We are so simple, and yet concise, as to be interesting 

and intellig'ble. The work is unincumbered with 
theoretical deductions, dealing wholly with the 
practical matter, which it is the aim of this compre- 
hensive text-book to impart. The accuracy of the 
analytical methods are vouched for from the fact 
that they have all been worked through by the 
author and the members of his class, from the 
printed text. We can heartily recommend the work 
to the student of chemistry as being a reliable and 
comprehensive oue. — Druggists' Advertiser, Oct. 
15, 1S77. 



therefore heartily commend it to stnden's, and espe- 
cially to those who are obliged to dispense with a 
master. Of course, a teacher is in every way desi- 
rable, but a good degree of tech nic il skill and prac- 
tical knowledge can be attained with no other 
instructor than the very valuable handbook now 
under consideration.— St Louis Clin. Record, Oct. 
1877. 

The work is so written and arranged that it can be 
comprehended by the student without a teacher, and 
the descriptions and directions for the various work 



Q.ALLOWAY {ROBERT), F.C.S., 

Pr^f of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 

don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $2 75. (Lately 
Issued.) 

The success which has carried this work through repeated editions in England, and its adop- 
tion as a text-book in several of the leading institutions in this country, show that the author 
has succeeded in the endeavor to produce a sound practical manual and book of reference for 
the chemical student. 

We regard this volume as a valuable addition to I acids, and of compounds and various secretions and 
the chemical text-books; and as particularly calcu- | excretions of animal origin. — Am. Jour, of Pharm., 
laied to iastruct the studeat in analytical researches I Sept. 1S72. 
of the inorganic compounds the important vegetable | 



R 



EMJEN(IRA), M.D., Ph.D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

PRINCIPLES OF THEORETICAL CHKMISTRY, with special reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. (Just Issued.) 



1XTOHLER AND FITTIG. 

r ' OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad. 

ditions from the Eighth German Ed. By Ira Remsen, M.D., Ph.D., Prof, of Chein. 
and Physics in Williams College, Mass. In one volume, royal 12mo.of 550 pp., cloth, $3. 



12 Henry 0. Lea's Publications— (Mat. Med. and Therapeutics). 



ARR1SH [EDWARD), 

Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 

l TREATISE ON PHARMACY. Designed as a Text-Book for tie 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae anu 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth. $5 50 ; leather, $6 50. 
(Lately Isstied.) 

the work, not only to pharmacists, hut also to the 
multitude of medical practitioners who are obliged 



Of Br. Parrisk's great work on pharmacy it only 
remains to be said that the editor has accomplished 
his work so well as to maintain, in this fourth edi- 
tion, the high standard of excellence which it bad 
attained in previous editions, uuder the editorship of 
its accomplished author. This has not been accom 
plished without much labor, and many additions and 
improvements, involvingchangesin the arrangement 
of the several parts of the work, and the addition of 
much new matter. With the modifications thus ef- 
fected it constitutes, as now presented , a compendium 
of the science and art indispensable to the pharma- 
cist, and of the utmost value to every practitioner 
of medicine desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
he prescribesforhispatients. — Chicago Med. Joum., 
July, 1874. 

The work is eminently practical, and has the rare 
merit of being readable and interesting, while it pre- 
serves a strictly scientific character. The whole work 
reflects the greatest credit on author, editor, and pub- 
lisher It will conveysomeideaoftbeliberality which 
has been bestowed upon its production when we men- 
tion thatthereare no less than 280carefully executed 
illustrations. In conclusion, we heanily recommend 



to compound their own medicines. It will ever hold 
an honored place on our own bookshelves. — Dublin 
Med. Press and Circular, Aug. 12, 1874. 

We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hands. It is a book with which no pharma- 
cist can dispense, and from which no physician can 
fail to derive much information of value to him in 
practice. — Pacific Med. and Surg . Jour n. , June, '74. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
" Parrish's Pharmacy'' is a well-known work on this 
side of the water, aud the fact shows us that a really 
useful work never becomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
posthumous edition of " Parrish r ' has been saved to 
the public with all the mature experience of its au- 
thor. an<i perhaps none the worse for a dash of new 
blood. — Lond. Pharm. Journal, Oct. 17, 1874. 



S 



TILLE [ALFRED), M.D., 

Professor of Theory and Practice of Medicine in the Univers-ity of Penna. 

THERAPEUTICS AND MATERIA MEDIOA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History . 
Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 
pages. Cloth, $10 ; leather, $12. {Lately Issued.) 



It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known aud excellent work.— Brit, and For. 
Med.-Chir. Review, Oct 1875. 

For all who desire a complete work on therapeutics 
and materia medica for reference, in cases involving 
medico-legal questions, as well as for information 
concerning remedial agents, Dr. Stille^s is "par ex- 
cellence'' 1 the work. The work being out of print, by 
the exhaustion of former editions the author has laid 
the profession under renewed obligations, by the 
careful revision, important additions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical executiou handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Lo lis Med. and Surp. Journal, Dec 1874. 

From the publication of the first edition "Stille's 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 



guage, a 



nd its presence supplies, in the two volumes 



of the present edition, a whole cyclopaedia of thera 
peutics. — Chicago Medical Journal, Feb. 1S75. 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profes.-ion, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict,as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and croton chloral nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminum, and other remedies. — Am. 
Joum. of Pharmacy, Feb. 1S75. 

We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present siate of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question.— Boston Med. and. Surg. Journal, Nov. 5, 
1S74. 



G 



RIFFITH [ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Pn par- 
ing and Administering Officinal and other Medicines. The whole adapted to Physiciar s and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, by John M. 
Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
and handsome octavo volume of about 800 pp., cl., $4 50 jleather, $5 50. (Lately Issued.) 



To the druggist a good formulary is simply indi 
■pensable, aud perhaps no formulary has been, more 
extensively used than the well-known work before 
us. Many physicians have toofflciate, also, as drug- 
gists. This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 
this kind is of benefit also to the city physician in 
largest practice.— Cincinnati Olinic, Feb. 21. 1S74. 



A more complete formulary than it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitioner 
who compounds his own medicines. Much of what 
is contained in the introduction ought to be com- 
mitted to memory by every student of medicine. 
As a help to physicians it will be found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind . 
— The American Practitioner, Louisville, July, '74 






Henry C. Lea's Publications — (Mat. Med. and Therapeutics). 13 



&TILLE [ALFRED), M.D, LL.D., and IfAJSCH [JOHN M.). Ph. 

*3 Prof, of Theory and Practice of Medicine -^- Prof, of Mat. Med. and Bot i 



in Phil a,, 
and of Clinical Med, in Univ. of Pa. Coll. Pharmacy. Secy, to the American 

Pharmaceutical Association . 

THE NATIONAL DISPENSATORY: Containing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 

the Pharmacopoeias of the United States and Great Britain. In one very handsome 

octavo volume of 1628 paees, with over 200 illustrations. Extra cloth, $6 75; leather, 

raised bands, $7 50. (Noiv Ready ) 

®Lg* As this work exceeds the limit of Four pounds allowed for transmission by book post, 

copies have been done up in two part's, specially for mailing, which can be had by those who 

desire to procure the work by mail. Price, free of postage, in cloth, $7 00 ; leather, §8.25. 

EXTRACT FEOM THE PEEFACE, 

"In the rapid progress of modern research, few subjects have of late years received greater acces- 
sions of facts than the group of sciences connected with materia medica and therapeutics. The 
new resources thus placed at the command of the pharmaceutist and physician have seemed to the 
authors to justify an attempt to make, from the advanced standpoint of the present day, a concise 
but complete statement of all that is of practical importance to both profession* — a digest in which 
that which is old and that which is new shall be so brought together as to give to the reader, within 
the most moderate practicable compass, all the details in pharmacology, pharmacy, and thera- 
peutics, which he is likely to need in his daily avocations. In the almost infinite accumulation of 
material, this has required a careful and conscientious sifting to discard that which is obsolete, 
untrustworthy, or comparatively trivial, without impairing the practical completeness of the 
work. That they have wholly accomplished their object the authors do not venture to claim ; but 
they can say that years of constant labor have been devoted to the task of producing a work to 
which the inquirer may refer with the certainty of finding everything which experience has stored 
up as worthy of confidence in the subjects embraced within its scope. 

"To this end there have been included all crude drugs and chemical and pharmaceutical prepa- 
rations officinal in the Pharmacopoeias of the United States and Great Britain, together with the 
more important medicines of the French Codex and German Pharmacopoeia, which are to some 
extent prescribed here, or which may serve for comparison with similar articles in the English and 
American standards. Besides these, a large number of drugs which are not recognized by any 
Pharmacopoeia, are often kept in the shops because they are prescribed by physicians or used in 
domestic practice. Some of these give promise of future importance, and in making a selection 
among this class of remedies, it was deemed best not to err on the side of exclusiveness. 

"The alphabetical order of arrangement has been adopted throughout, as being on the whole 
the most convenient for reference. In this the non-' fiicinal medicines have been included with 
the officinal, the latter being distinguished by an affix, showing the Pharmacopoeia, to which they 
have been admitted. The title of each article is followed by a full synonymy, English, French, 
and Gsrman, together with Latin appellatives and popular names, such as are occasionally used in 
prescriptions anu standard works, or through which articles may be recognized. As all suostan >es 
have thus their appropriate place in the body of the work, but little is left for the Appendix, 
in which may be found the leading reagents, tables of weights and measures, comparisons of the 
scales of different hydrometers, alcoholometers, and thermometers, etc. 

" With regard to Pharmacodynamics, there is presented, for the first time in a Dispensatory, a 
succinct account of the physiological action of medicines. The results of experiments are stated 
as clearly as possible, and occasionally in the theoretical language of the day; but, as a rule, 
terms have been employed whose meaning is not likely to become obsolete or unintelligible. 

" In treating of Therapeutics, the most trustworthy results of clinical experience are concisely 
set forth, without discussing the grounds on which they rest. 

" Another feature, novel in a Dispensatory, is the Therapeutical Index. Care has been taken to 
render it as complete as possible, in order that the inquirer ma}' be enabled to learn by its means 
all of the more important medicines that have been employed in the treatment of each disease. 
Such an Index thus becomes, to some extent, a therapeutical classification of medicines, and it is 
believed must greatly enhance, by its suggestiveness, the working value of the bjok to the prac- 
titioner." 

The very thorough manner in which the authors have carried out their plan may be judged 
from the extent ot the Indexes. Thus the "Index of Materia- Medica'' covers 5i> triple- 
columned pages, and contains 10,4 15 references. The "Therapeutical Index," which gives 
under the head of each disease the principal remedies recommended for its treatment, occupies o'6 
double-coluoined pages, and contains 3767 references. 



F 



ARQUHARSON [ROBERT), M.D. , 

Le'-.txurer on Materia Medica at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS. Edited, with Additions, embracing 

the U. S. Pharmacopoeia. By Frank Woodburv, M.D. In one neat rojal 12mo. 
volume of over 400 pages : cloth, $2. (Just Issued.) 
Many persons who learned therapeutics before it straight across the page, we at once perceive the 
the physiological action of remedies was taught to relations of the one to the other. On this account, the 
students find it difficult to discover the bearing of \ work is likely to be useful, not only to student* pie- 
physiological action on therapeutic employment ! p.triug for their examinations, but'to tho.-e medical 
from ordinary textbooks. Dr. Farquharson has most men, also, who are well acquainted with larger 
ingeniously shown it by printing the two in parallel books on the same subject, bat experience the diffi- 
coiamns and corresponding paiagra jhs, so ihat, by culty, already mentioned, of seeing the relations 
running the eye down the left-hand side of a page we between the "actions and a<e of remedies. — The 
get the physiological actions of a drug, and on the London Practitiontr, January, 1S7S. 
right-hand the therapeutical uses, while, by running 



14 



Henry C. Lea's Publication s~-~(P^/wmY^, &c). 



AND 



flORNIL (V.), 

Prof, in the Faculty of Med , Paris. 



J^ANVIER (L.), 

Prof, in the College of France. 

MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D , Pathologist and Ophthalmic Surgeon 
to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
of Penna. In one very handsome octavo volume of about 6C0 pages, with over 300 illus- 
trations. (Preparing.) 

So much has been done of late years in the elucidation of pathology by means of the micro- 
scope, and this subject now occupies so prominenta position as one of the most important branches 
of medical science, that the American profession cannot fail to -welcome a translation of the pre- 
sent work, which, through its own merits and through the well-known reputation of its distin- 
guished authors, is regarded in Europe as the standard text-book and work of reference in its 
department. Such investigations and discoveries as have been made since its appearance will be 
introduced by the translator, and the work is confidently expected to atsume in this country the 
same position which has been so universally accorded to it a broad. 



ipENWICK (SAMUEL), M.D., 

-*■■ Assistant Physician to the London Hospital^ 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo., cloth, $2 25. {Just Issued ) 



Of the m*ny guid»-books on medical diagnosis, 
claimed to be written for the special inst' -notion of 
students, this is the best. The author is evidently a 
well read and accomplished physician. and he knows 
how to teach practical medicine. The charm of sim- 
plicity is not the l.eastint restingfeaturein the man- 
ner iu which Dr. Fenwickconveysinstruciion. There 



are few books of this size on practical medicine that 
contain so much and convey it so well as che volume 
before us I* i* a book we can sincerely recommend 
to the student fir direct instruction, and to the prac- 
titioner as a ready and useful aid to his memory. — 
Am. Jo urn. of Syphilography, Jan. 1874. 



G 



KEEN (T. HENRY), M.D. , 

Lecturer on Pathology and Morbid Anatomy at Gliaring -Cross Hospital Medical School, etc. 

PATHOLOGY AND MORBID ANATOxMY. Third American, from 

the Fourth and Enlarged and Revised English Edition. In one very handsome octavo 
volume of 332 pages, with 132 illustrations; cloth, $2 25. (Just Ready.) 

ciently numerous, and usual y well made. In the 
p esent edition, such new matter has been added as 
was necessary to embrace the la'er results in patho- 
logical research. No doubt it will continue to enjoy 
the favor it has received at the hands of the profes- 
sion. — Med and Svrg. Reporter, Feb. 1, 1S79. 

For practical, ordinary daily n c e, this is undoubt- 
edly the best treatise that is offered to students of 
pathology and morbid anatomy. — Cincinnati Lan- 
cet and Clinic, Feb. S, 1S79. 



This is unquestionably one of the best manuals on 
the subject of pathology and morbid anatomy that 
can be placed in the student's hands, and we are 
glad to see it kept up to the times by new editions. 
Each edition is carefully revi.-ed by the author, with 
the view of making it include the most recent ad- 
vances in pathology, and ot omitting whatever may 
hn.ve become obsolete.— N. Y. Med. Jour., Feb. 1S79. 



The treatise of Dr. Green is compacc, clearly ex 
press d, up to the times, and popular as a. text-hook 
both in England and America. The cuts are sufii 



D 



AVIS (NATHAN S.), 

Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 

being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royal 12mo. volume. Cloth, $1 75. (Lately Issued.) 



WHAT TO OBSERVE AT THE BEDSIDE AND AFTER 
Death in Medical Cases. From the second Lou- 
don edition. 1 vol royal 12m-o., cloth. $1 00. 

CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and SI 3 larsrp ^ood-enarravinsrs By R 
Eqlesfield Griffith, M. D. One vol.Svo., pp. 100C , 
cloth. $4 00. 

CARPENTER'S PRIZE ESSAY ON THE USE OI 
Alcoholic Liquors in Health and Disease. Nev 
edition, with a Preface by D. F. Condte. M.D., anc 
explanations of scientific words. In one neat 12mo. 
volume, pp. 178, cloth. 60 cents. 

GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY 
Translated, with Notes and Additions, by Joseph 
Leioy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological. Etiological, andTherapeu 
tical Relations. I n two large and handsome oetav o 
volumes of nearly 1500 pages, cloth. $7 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. Svc, pp. 500, cloth. $3 50. 



BiSLOW'8 MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condi b, 
M D. 1 vol. 8vo., pp. 600. cloth. *2 SO 

TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pages, 
cloth. $2 50 

STURGES'S INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Being a Guide to the In- 
vestigation of Disease. In one handsome 12mo. 
volume, cloth, $1 25. (Lately Issued.) 

STOKES' LECTURES ON FEVER Edited by John 
William Moore, M.D. , Assistant Physician to the 
Cork Street Fever Hospital. In one neat Svo. 
volume, cloth, $2 00. (Just Issued.) 

THE CYCLOPiEDIA OF PRACTICAL MEDICINE: 
comprising Treatises on the Nature and Treatment 
of Diseases, Materia Medica and Therapeutics, Dis- 
eases of Women and Children, Medical Jurispru- 
dence, etc. etc. By Dt/ngljson, Forbes, Tweedie, 
and Conollv. In four large super royal octavo 
volumes, of 3254 double-columned pages strongly 
and handsomely bound in leather, $15; cloth, $11. 



Henry C. Lea's Publications — {Practice of Medicine). 



15 



JpLINT {AUSTIN), M.D., 

**• Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 

edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 

pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Irately Issiied. ) 

By common consent of the English and American medical press, this work has been assigned 

t , the highest position as a complete and compendious text-book on the most advanced condition 

ft! medical science. At the very moderate price at which it is offered it will be found one of the 

cheapest volume? now before the profession. 

This excellent treatise on medicine has acquired ■ trfbutions to medical literat nre both in this "ountry 
for itseif in the rrnited States a reputation similart>> | md in Europe, have received careful attention, so 
thatenioyed in England by the admirable lectures that some portions have been entirely rewritten, and 



of Sir Thomas Wats.«n. It may not possess rhe same 
charm of style. but it has, like solidity, the fruit of 
long and patient observation, and presents kindred 
moderation and eclecticism. We have referred to 
many of the most i mportant chapters and Sod the re- 
vision spoken of in the preface is a genuine one. and 
that the author has very fairly brought ur> bis mat 'er 
to the level of the knowledge of che present day. The 
work has thisgreatrecommendatiou, that it is in one 
volume, and therefore will not oe so terrifying to the 
student as the bulky volumes whicb several of our 
Eaarlish text-books of medicine have developed into. 
— British and Foreign M?d.-Chir. Per., Jan. 1S7A. 



about seventy pages of new matter have been added. 
—Cnicogn M^d Jonrn., June, 1873. 

Has never been surpassed as a text-book for stu- 
dents and a book of ready reference for practitioners. 
The force of its logic, its simple and practical teach- 
ing-. h?ve left it without a rival in the field — N. Y. 
Med Record, Sept 1">, 1874 

Prof. Flint, in the fourth edition of his grept work, 
has performed a labor reflecting much credit upon 
lrmself.andconferringalastingbenefitupon the pro- 
fession. The whole work shows evidence of thorough 



revision, so that it appears like a new book w>itten 
I expressly for the times For thegeneral practitioner 
Itisofcourse unnecessary to introduce or eulogize ; a>:d student of medicine, we cannot recommend the 
this now standard treatise All the colleges recom- I book in too strongterms — A T . Y Med. Jour .Sept '73. 

Tt is given to very few men to tread in the steps of 
Austin Flint, whose single volume on medicine, 



mend it as a text-book, and there are few libraries 

in which one of its editions is not to be found. The 

present edition has been enlarged and revised fobringj :fc „ ugh here and there defective, isa m 

U up to the authors present level of experience and | i,,^ condensation and of general grasp of an enor- 

reading. His own clinical studies and the latest con- ! raoU sly wide subject — Land. Practitioner,Dec. '73. 



JgT THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal l2mo. volume. Cloth, $1 3S. (Just Issued) 



WOODBURY {FRANK), M.D., 

Physician to the German Hospital, Ph'ladelplv.a, late Physician to the Out-patient Department 
ofihiJeff College Hospital etc. 

A HANDBOOK OP THE PRINCIPLES AND PRACTICE OF 

Medicine ,- for the use of Students and Practitioners. Based upon Husband's Handbook 
of Practice. In one neat volume, royal 12aio. 



fJARTSHOBNE {HENRY), M.P., 

*■•*- Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OP THE PRINCIPLES AND PRACTICE OF MED1- 

CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12mo volume, 
of about 550 pages, cloth, $2 63 ; half bound, $2 88. {Lately Issued.) 

advances in medicine, is admirably condensed, and 
yet sufficiently explicit for all the purposesintended, 
thus makiue it by far the best work of its character 
ever published— Cincinnati CHr.ic. Oct. 24, 1874. 

Without doubt the best book of the kind published 
in the English language. — St. Louis Mtd. a.nd Sv.r g . 
Joum , ^'ov. 1S74. 



Asa handbook, which clearly sets forth the essen- 
tials of the principles A.ND PRACTICE OF MEDICINE, We 
do not know of its equal — Va. Med. Monthly. 

As a brief, condensed, but comprehensive hand- 
book, it cannot be improved upon. — Chicago Med 
Examiner, Nov. 15, 1874 

The work is brought fully up with all the recent 



TJTATSON {THOMAS), M.D., g-c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
tions, by Hexry Hartshorns, M.D., Professor of Hygiene in the University of Pennsylv a . 
nia. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) 



Tt is a subject for congratulation and for thankful- 
ness that Sir Thomas Watson, during a period of com- 
parative leisure, after a long, laborious, and most 



portant pathological and practical questions, there- 
suits of his clear insight and his calm judgment are 
now recorded for the bene fit of mankind, in language- 
honorable professional career, while retaining full which, for precision, vigor, and classical elegance, ha * 
possession of his high mental faculties, should have rarely been equalled, and'never surpassed The re- 
prnployed the opportunity to submit his Lectures to vision has evidently been most carefully done, and 
a more thorough revision than was possible during the results appearin almosl every page.— Brit Med 
the earlier and busier period of his life. Carefully : Tourn , Oct. 14, 1S71. 
passingia review some of the most intricate and iiu- ■ 



16 



Henry C. Lea's Publications— -(Practice of Medic me). 



JDRISTO WE [JOHN SYER), M.D., F.R.C.P., 

-*-J Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. 

A MANUAL ON THE PRACTICE OF MEDICINE. Edited, with 

Additions, by James H. Huichinson, M.D., Physician to the Penna. Hospital. In one 
handsome octavo volume of over 1100 pages : cloth, $5 50 ; leather, $6 50. (Just Issued.) 
Dr. Bris'owe ha? long been before the profession 
as an able thinker and writer on professional sub- 
jects. His present work is second to none of its 
kind, the part on diseases of the nervous system 
being. p?rhaps, the most deserving of praise. It is 
eminently readable, both in matter and print, and 
fully deserves the success it is sure to obtain. — 
Edin. Med. Journ., Oct. 1S77. 



The treatment of the various diseases is admirably 
summed up, and we pronounce Dr. Bristowe's book 
to be eminently practical on this subject. We give 
the author our hearty congratulations, and his book 
our best commendations and wish it all success. — 
Loud Med. Times and Gaz. Sept. 15 1877. 

This portly volume is a model of condensation. 
In a style at once clear, interesting, and concise, Dr. 
Bristowe passes in review every couceivable subject 
connected with the practice of medicine. Those 
practitioners who purchase few books will find' this 
a mort opportune publication, because s-o many top- 
ics not usually emtuaced in a work on practice are 



adequately handb d. Thebookis a thoroughly good 
one, and its usefulness to American readers has been 
increased by the judicious notes of the Editor. — 
Cincinnati Clinic, Jan. 7, 1877. 

Anyone who wants a good, clear, condensed work 
upon Practice, quiteup with the mostrecent viewsin 
pathology, will find this a most valuable work. The 
additions made by Dr. Hutchinson are appropiiate 
and useful, andso well done that wewish there were 
more of tbem. —Am Practitioner, Feb. 1S77. 

Upon the whole, we know of no work which we 
could more confidently recommend to the student. or 
the practitioner, intending a review of the field of 
theory and practice, than this book of Dr. Bris- 
towe's. We thus commend it, becanse (he vast ar- 
ray of facts pertaining to the practice of medicine, as 
it is to. day, are here presented ably, and with that 
method, order, and perspicuity which, in all depart- 
ments of education, distinguish the lessons of an ac- 
ceptable and profitable teacher — Chicago Med. 
Jnurn. and Examiner, Aug. 1S77. 



TJABERSHON (S. 0.), M.D. 



Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's 
Hospital,, etc. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes- 
tines, and Peritoneum. Second American, from the third enlarged and revised [Eng- 
lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
(hi Press.) 
This work has remained s'me time out of print owing to the careful and conscientious 
revision which it has enjoyed at the hands of the author, and which has nearly doubled its 
size since the appearance of the first edition. Yet there is no work accessible to the profession 
to take its place, as a careful, practical guide on a class of diseases, which form so large and 
important a portion of the duties of the physician, and for which the author's position has 
given him almost unequalled opportunities for observation and experience. 



P 



OTHERG1LL {J. MILNER), M.D. Edin., M.R.C.P. Lond., 

Asst. Phys. to the West Lond Hosp. : Asst. Phys. to the City of Lond. Hosp.,efc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT 



Or, the 



Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, 

$4 00. {Novj Ready.) 
It ^nay be said that the scope of this work is not dissimilar to that of the well-known 
" Principles ot Medicine,' 1 by Dr. J. C. B. Williams, now long out of print, which in its day 
met with such unusual acceptance. More practical in its character, however, it seeks to bring 
to the aid and elucidation of positive therapeutics, the vast accumulation of scientific facts and 
theories made by the presentgeneration, pointing out the measures to be adopted at the bedside 
and establishing them on firm rational grounds. 



Our frienus will find this a very readable book ; and 
that it sheds light upon every theme it touches, causing 
the practitioner to feel more certain of his diagnosis in 
difficult cases. We confidently commend the work to 
our readers as one worthy of careful perusal. It lighis 
the way over obscure and difficult passes in medical 
practice. The chapter on the circulation of the blood 
is the most exhaustive and instructive to be found. It 
is a book every practitioner needs, and would have, if 
he knew how sugi>> stive and helpful it wou'd be to 
him.— St. Louis Med. and Surg.Joum., April, 1877. 

It is our lion est conviction, after a careful perusal ot 
this goodly octavo, that it represents a great amount ot 
earnest thought and painstaking work, and is therefore 
one of those books which both deserve and are likely to 
survive. This book, although written ostensibly for the 
young and inexperienced, may be very profitably studied 
by those who have been practising their profession 
more or less empirically for thirty or forty years. We 
particularly recommend the chapters on Public and 



Private Hygiene, Food in Health and Ill-Health, and 
the Conclusion— the Medical Man at the Bedside. The 
last is high-toned, and indicates much shrewdness of ob- 
servation. Our space will not admit of further quotation . 
We content ourselves with again recommending the 
book very cordially. — Edin. Med. Journ., Jan. 1877. 

We heartily commend his book to the medical student 
as an honest and intelligent guide through the mazes of 
therapeutics, and assure thepractitioner who has grown 
gray in the harness that, he will derive pleasure and in- 
struction from its perusal The imperfections and 
errors which we have noticed are few and unimportant. 
On the other hand, the excellences are many and patent. 
Valuable suggestions and material for thought abound 
throughout. The chapters on body heat and fever, in- 
flammation, action and inaction, and the urinary sys- 
tem are particularly good. The descriptions of patho- 
logical conditions, and the character of the therapeutic 
measures advised <nve evidence of sound clinical obser- 
vation.- Boston Med. and Surg. Journal, Mar 8, 1877. 



~DY THE SAME AUTHOR. 

THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT 

IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal 
12mo. of 156 pages; cloth, $1 00. (Just Ready.) 
It will be found a highly interesting study and I certain drugs. — Medical and Surgical Reporter, 
practical application of the antagonistic action of 1 Sept. 11, 1878. 



Henry C.Lea's Publications — {Practice of Medicine). 



n 



fPlNLAYSON (JAMES), M.D., 

-*- Physician a*d Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 

titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with S5 illustra- 
tions. Cloth, $2 63. {Just Ready.) 
The concurrence of gentlemen specially familiar with the several subjects being requisite to 
the satisfactory development of a plan so extensive, Dr. Finlayson has secured the co-operation 
of Prof. Gairdner, who has contributed the chapter on the Physiognomy of Disease ; Prof. Wrn. 
Stephenson that on Disorders of the Female Organs; Dr Alex Robertson that on Insanity; 
Prof. Samson Gemmell those on the Sphy^mograph and Physical Diagnosis; and Dr. Joseph 
Coates those on the Fauces, Larynx, and Nares, and on the method of performing post-mortem 
examinations. Other chapters have enjoyed the advantage of revision by gentlemen specially 
versed in their several subjects; and the volume is presented as thoroughly on a level with 
the most advanced condition of knowledge in a department which has made such rapid strides 
of advancement within the last few years. 



The book is an excellent one, clear, concise, conve- 
nient, practical. It is replete with the very know- 
ledge the student needs when he quits the lecture- 
room and the laboratory for the ward and sick-room, 
and does not lack in information that will meet the 
wants of experienced and older men.— Phila. Med. 
Times, Jan. 4, 1S79. 

The aim of 'he a.uthor is to teach a student and 
practitioner how to examine a case so as to use " ill 
his knowledge.'" in arriving at a diagnosis. All the 
various symptoms of the -everal system 1 - are grouped 
together in such a manner as to make their rela'ions 
to a final diagnosis clear and easy of apprehension. 
This work has been done by men of large experience 
and trained observation, who have been long recog 
niztd as authorities upon the subj.-cis which they 
treat. There is a profusion of illustrations to illus- 
trate subjects under discussion. The application of 
electricity, and instruments of precision in diagnosis, 
is fully discussed. This book is all good. We com- 
mend it to all students and practitioners of medicine 

as a work worthy of a place in their libraries. — Ohio \ and Surg., Jan. IS 
Med. Recorder, Dec. 1S78. 



This is one of the really useful books It is attrac- 
tive from pr face to the final page, aud ought to be 
given a place on very office table, because it contains 
in a condensed form all that is valuable in semeiology 
and diagnostics to be found in bulkier volumes, and 
because in its arrangement aud complete index, it is 
unusually convenient for quick reference in any 
emergency t bat may come upon the busy practitioner. 
— N. 0. Med. Joum., Jan. 1S79. 

This is a most important work for students, and 
one that is destined to become rapidly popular. It 
is composed of contributions from various eminent 
sources bearing upon this subject The real seci-et 
of successful practice is the accurate diagnosis of 
disease. This manual teaches the student to arrange 
his investigation in such system as to enable him, 
wich practice, to acquire this very desirable faculty. 
The division of the subject, as in this work, among; 
the highest authorities living, is a good idea, and 
gives us in one compact form a series of monographs 
written by masters. — Nashville Journal of Med. 



H 



AM1LTOX {ALLAN McLANE), M.D., 

Attending PhyHcian at the Hospital for Epileptics and Paralytics. BlackwelPs Island, N. Y. 
and at the Old- Patients 1 Department of the New York Hosj>iial. 

NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. 



In one handsome octavo volume of 512 pa« 
This is unquestionably the best and most com- 
plete text-book of nervous diseases that has yet ap- 
peared, and were international jealousy in scientific 
affairs at all possible, we might be excused fir a 
feeling of chagrin that it should be of American 
larentajro. This work, however, has been performed 
in New York, and has been so well performed that 
no room is left for anything but commendation. 
With great skill, Dr. Hamilton has presented to his 
readers a succinct and lucid survey of ail that is 
known of the pathology of the nervous system, 
v : ewed in the light of the most recent researches. 
From the preliminary description of the methods of 
examination and study, and of the instruments of 
precision employed in the investigation of nervous 
diseases, up till the final collection of formulae, tfce 
book is eminently practical. — Braiii, London, Oct. 
IS7S. 

The author tells us in his preface that it has been 
his object to produce a concise, practical book, aud 
we think he has been successful, considering the ex- 
tent of the subject which he has undertaken In 
fact, it is more extensive than the title property or 
accurately indicates, embracing— besides what are 
usually regarded as nervous diseases — inflammatory 
affections, both acute and chronic, hemorrhages and 
tumors of the cerebrum and cerebellum, medulla 
oblongata, spinal cord and nerves, with thrombosis 
and embolism of the arteries, sinuses, and veins. 
The reader may therefore expect information, more 
or less full and satisfactory, on almost every point 



ges, with 53 illus. ; cloth, $3 50. {Just Ready.) 
connected with the nervous system We have -on 
hesitation in saying that reliauce may be placed on 
Dr. Hamilton's cocscientious peiformnnceor his self- 
assigned task, on his soundness of judgment, aud 
freedom from empiricism. — Edinburgh Med,. Joum., 
Oct 1S7S. 

From a very careful examination of the whole 
work, we car* justly say that the author has not only 
clearly and fully treated of diagnosis and treatment, 
but. unlike most works of this class, it is very com- 
prehensive in regard to etiology, and exposes the 
pathology of nervous diseases i u the light of the very 
late-t experiments >uid discoveries. The drawings 
are excellent and well selected. After this careful 
revision, we can heartily recommend this work to 
students and general practitioners in particular as 
being a full expo-ition of aiseases of the nervous sys- 
tem, their pathology and treatment, to date.— N. Y. 
Med. Record, Aug" 3, 1STS. 

As stated in the preface, the author's object has 
been to wri'e a concise and practical book, for 
which there is certainly a place, and we think he 
has succeeded admirably in fulfilling his object. 
The usual plan is adopted in the classification of 
the d fferent disease-;, the book not being greatly 
unlike Hammond's in this respect, although it is 
very noticeable throughout that the author's opin- 
ions vary widely from those of Dr Hammond. — Am. 
Supp. O^std. Joum. Great Britain and Ireland, 
July, 1S78. 



QHARCOT {J. M.), 

Professor to the. Faculty of Med. Paris, Phys. to La Salpe'riere, etc. 

LECTURES ON DISEASES OP THE NERVOUS SYSTEM. Trans- 
lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, 
etc., Cath. Univ. of Ireland. With illustrations. {Publishing in the Medical Nev s and 
Library, commencing with the July No. 1878 See page 2 ) 



18 Henry C. Lea's Publications— ( Diseases of the Chest, &c). 
THROWN {LENNOX), F.R.C.S. Ed., 

"*\ Senior Surgeon to the Central London Throat and Ear Hospital, etc., 

THE THROAT AND ITS DISEASES. With one hundred Typical 

Illustrations in colors, and fifty wood engravings, designed and executed by the author. 

In one very handsome imperial octavo volume of 351 pages ; cloth, $5 00. (Now Ready.) 

The author's rare artistic skill has been utilized j pa^es, and the colored lithographs are very beau v 

in the production of one hundred beautiful iliustra- i fully executed, and very 

i . . , .i . -i i _«• ii.. ,.:_ j v... „„ „^ si &-,.„. „*„*.! 



Canada Mtd. 



tions in colors, the very best of the kind we have 
seen, and which have been distributed in ten plates. 
Fifty wood enaravings, designed and executed by 
the authrr, appear in the bo*y of the work — these 
are unusually accurate. In conclusion, we recom- 
mend this beautiful volume as an acceptable addi- 
tion to the library of those engaged in the treatment 
of diseases of the throat.— N. Y. Med. Record, Nov. 
9, 1S7S. 

There is much instruction to be gained from these 



nd very trntliful. 
and Surgical Journal, Sept. 187S. 

Wood-cuts are freely interspersed throughout its 
pages, and lastly, w< would draw attention to the 
colored plates, ICO in number, the majority of 
which are excel ! ent aDd most artistic We can 
heartily recommend this work to the medical reader ; 
it is well printed in clear type, handsomely got up, 
aDd does credit to both author and publishVr.— Ed- 
inburgh Medical Jour., Aug. 1S78. 



fi^LINT {AUSTIN), M.D., 

Pr»fessor of the Principles and Practice of Medicine in Bellevite Hospital Med. College, A r Y. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume: $3 50. (Lately Issued.) 
This book contains an analysis, in the author's lucid I mend the book to the perusal of all interested in the 
style, of the notes which he has made in several nun- study of this disease. — Boston Mtd. and Surg. Journal, 
tired ca«es in hospital and private practice. We com 1 Feb 10, 1876. 



OT THE SAME AUTHOR. (Just Issued .) 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In 
one handsome royal 12mo. volume: cloth, $1 75. 

We can confidently recommend this treatise to all I rightly valne these modes of exploration of disease. 
who would learn auscultation aud percussion, and | —British and For. Med.-Chir. Rev., July, 1S77. 

T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 

Dr. Flint chose a difficult subject for his researches, i,nd clearest practical treatise on those subjects, and 
and has shown remarkable powers of observation i should be in the hands of all practitioners and Btu- 
and reflection, as well as great industry, iD his treat- ients. It is a credit to American medical literature, 
ment of it. His book must he considered the fullest I -Arner. Journ. of the Med. Sciences, July, 1S60. 



B 



Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 



WILLIAMS'S PULMONARY CONSUMPTION; its 
Nature, Varieties, and Treatment. Wiih an An- 
alysis of Oue Thousand Cases to exemplify its 
duration. In one neat octavo volume of about 
350 pages ; cloth, $2 50. 

DIPHTHERIA ; its Nature and Treat uent, with an 
account of the History of its Prevalence in vari- 
ous Countries. By D D Sladk, M.D. Second and 
revised edition. In one neatroval 12mo. volume, 
cloth, $1 25. 

W ALSHE ON THE DISEASES OF THE HEART ANT 
GREAT VESSELS. Third American edition. ? n 
1 -col. 8tt-o.. 4<?0 vv.. cloth. *3nn 

LECTURES ON THE DISEASES OF THE STOMACH. 
With an Introduction on its Anatomy and Physio- 
logy. By Wit,i,fam Brtnton, M.D., F R S From 
the second and enlarged LondoneditiOn. With il- 
lustrations on wood Iu one handsome octavo 
volume of about 300 pages; cloth, $3 26. 

LA ROCHE ON PNEUMONIA. 1 vol. Svo., cloth, 
of 500 pages Price $3 00. 

LINCOLN'S ELECTRO-THERAPEUTICS; a Concise 
Manual of Medical Electricity. In one very neat 
royal 12mo. volume, cloth, with illustrations, $1 50. 

CLTNTCAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS BvC. Handpield Jones, 
M.D., Physician to St. Mary's Hospital, &c. Sec- 
ond American Edition. In one handsome octavo 
volume of 318 pages, cloth, $3 25. 



p'ULLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical Diagnoais, 
Symptoms, and Treatment. From the second and 
revised English editiou. In one handsome ocatvo 
volume of about 500 pages ; cloth, $3 50. 

CHAMBERS'S MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome 
octavo volume. Cloth, $2 75 

CHAMBERS'S RESTORATIVE MEDICINE. An Har- 
veian Aunual Oration. With Two Sequels. In 
one very handsome vol. small 12mo , cloth, $1 00. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one hand- 
some volume, small octavo, cloth, $2 00. 

PAVY'S TREATISE ON FOOD AND DIETETICS. 
Physiologically and Therapeutically Considered. 
In one handsome octavo volume of nearly 600 
pages, cloth, $4 75. 

S>IITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. Svo. , pp. 254. *9?A 

BASHAM ON RENAL DISEASES: a Cliuical Guide 
to their Diagnosis and Treatment. With Illustra- 
tions. In one 12mo. vol. of 304 pages cloth, $2 00. 

LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I. A., Physician to the Meath 
Hospital. In one vol. Svo., cloth, $2 50. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K C C. In one octavo volume of 362 pages, clotii, 
$2 25. 



Henry C. Lea's Publications — {Venereal Diseases, &c), 19 



J>UMSTEAD {FREEMAN J.), M.D., 

-^-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Third edition 
revised and enlarged, with illustrations. In one large and handsome octavo volume of 
over 700 pages, cloth, $5 00 ; leather, $fi 00. 
In preparing this standard work again for the press, the author has subjected it to a very 
thorough revision. Many portions have been rewritten, and much new matter added, in order to 
bring it completely on a level with the most advanced condition of syphilograohy, but by careful 
compression of the text of previous editions, the work has been increased by only sixty-four pages. 
The labor thus bestowed upon it. it is hoped, will insure for it a continuance of its position as a 
complete and trustworthy guide for the practitioner. 

A valuable work on Venereal Diseases, which not J venereal diseases, that it may seem almost superflu- 
ooly has a wide circulation in this country, and I oas to say more of it than that a new edition has been 



been accepted as the standard, but appears to have 
formed the basis, to a large extent, of many of the 
books and articles which have been written on the 
same subject and published in England.— The Gins- 
g >w Mtrf. Journ... Oct. 1S77. 

It is the most completebook with which we are ac- 
quainted in the language. The latest views of the 
best authorities ai-e put forward, and the information 
is well arranged — a great point for the student and 
■'.till more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
Hie treatment of syphilis by repeated inoculations, are 
very fully discussed. — London Lancet. Jan. 7. 1871. 

Dr. Bumstead's work is already so universally 
known as the best treatise in the English language on 



issued. But the author's industry has rendered this 
D3w edition virtually a new work, and so merits as 
much special commendation as if its predecessors hao 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician's practice, the volume before 
us is bv far the best of which we have knowledge.— 
N. Y. Medical Gazelle. Jan. 28, 1871. 

It is rare in the history of medicine to find any one 
book which contains all* that a practitioner needs to 
know; while the possessor of "Bumstead on Vene- 
real"' has no occasion to look outside of its covers for 
anything practical connected with the diagnosis, his- 
tory, or treatment of these affections. — N. Y. Medical 
Journal, March, 1871. 



flULLERIER (A.), and 

^> y Surgeon to the Hdpiial du Midi. 



J?UMSTEAD (FREEMAN J.), 

■*-* Professor of Venereal Diseases in the College of 
Physicians and Surgeons. N. Y. 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth. $17 00 ; also, in five part?, stout wrappers, at $3 per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are Interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 

We wish for once that our province was not restrict- [ to its end, we do not know a single medical work, 
ed to methods of treatment, that we might say some- i ;vhich for its kind is more necessary for them to have, 
thing of the exquisite colored plates in this volume. I —California Med Gazette March. 1S69. 
-London Practitioner, May, 1S69. The most splendidly illustrated work in the Ian 

As a whole, it teaches all that can be taught by I ? uage. and in our opinion far moje useful than the 

French original. — Am. Journ. Med. Sciences, Jan. 69. 
The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers.— Bost Med and Surg. J 7 ., Jan. 14 1R69. 

Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is 
however, an additional interest and value possessed 
by the volume before us : for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
Dr. Bumstead, as an authority, is without a rival I dental remarks by one of the most eminent American 
Assuring our readers that these illustrations tell the | syphilographers, Mr. Bumstead. — Brit, and For. 
whole history of venereal disease, from its inception | Medico- Chir . Review, July, 1869. 



means of plates and print. — London Lancet, March 
IS 3 1869. 

Superior to anything of the kind ever before issued 
on this continent. — Canada Med. Journal, March, '69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published. — 
Dominion Med. Journal, May, 1S69. 

This is a work of master ha.Eds on both sides. M 

Cullerier is scarcely second to, we think we may truly 

say is a peer of the illustrious and venerable Ricord, 

'hile in this country we do not hesitate to say that 



JjEE (HENRY), 

Prof, of Surgery at the R >ya I College of Surgeons of England, etc. 

LECTURES ON SYPHTLTS AND ON SOME FORMS OF LOCAL 

DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 



handsome octavo volume: cloth; $2 25. 
The work is valuable, as it treats quite fully of sub 
eets which are not dwelt upon in the systematic works 
of other English authors of the present day. as the inoc- 
ulability of syphilitic blood : the conditions under which 
the secretions of primary and secondary syphilitic man- 
ifestations maybe inoculated naturally Or artificially; 
the morbid processes produced by such inoculation ; the 



{Lately Published.) 
modifications of these processes in patients previously 
syphilitic: primary and secondary syphilitic diseases of 
the mucous membranes and their liability to commu- 
nicate constitutional syphilis, etc. The book is full of 
clinical material illustrating th*=e topics, original or 
quoted.— Archives nf Dermatology, April, 1876. 



H 



ILL BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. 

one handsome octavo volume ; cloth, $3 25. 



In 



20 Henry 0. Lea's Publications-— (Diseases of the Shin, &c). 
'£10 X {TILBURY), M.D., F.R.C.P.,and T. C. FOX, B.A., M.R.C.S., 

-*- Physician to the Department for Skin Diseases, University College Hospital. 

EPITOME OP SKIN DISEASES. WITH FORMULAE. For Stu- 
dents and Practitioners. Second edition, thoroughly revised and greatly enlarged. In 
one very handsome 12mo. volume of about 250 pages. (Li Press.) 

T^TILSON {ERASMUS), F.R.S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 
enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. 

A SERIES OF PLATES ILLUSTRATING " WILSON ON DIS- 
EASES OP THE SKIN ; " consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most cf 
them the size of nature. Price, in extra cloth, $5 50. 

Also,, the Text and Plates bound in one handsome volume. Cloth, $10. 

£>Y THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 
eases of the skin. In one very handsome royal 12mo. volume. $3 50. 

J^ELIGAN (J. MOORE), M.D., M.R.I. A. 

ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

volume, with exquisitely colored plates, &c, presenting about one hundred varieties of 
disease. Cloth, $5 50. 
The diagnosis of eruptive disease, however, under 
alL circumstances, is very difficult. Nevertheless, 
Dr. Neligan has certainly, "as far as possible," given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
drawing a diagnosis as to the class, order, and species 



io which the particular case may belong. While 
looking over the "Atlas" we have been induced to 
examine also the "Practical Treatise." and we are 
inclined to consider it a very superior work, oon- 
bining accurate verbal description with sound viev s 
of the pathology and treatment of eruptive diseases 
— Glasgow Med. Journal. 



TJILLIER {THOMAS), M.D., 

Physician to the Skin Department of University College Hospital, &c- 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 

Second Am. Ed. In one royal 12mo. vol. of 358 pp. With Illustration? Cloth, $2 25. 



We can conscientiously recommend it to the stu 
dent; the style is clear and pleasant to read, the 
matter is good, and the descriptions of disease, with 
the modes of treatment recommended, are frequently 
illustrated with well-recorded cases. — London Med. 
Times and Gazette. April 1, 1865. 



It is a concise, pLain, practical treatise on the vari- 
ous diseases of the skin ; just such a work, indeed, 
as was much needed, both by medical students and 
practitioners. — Chicago Medical Examiner, May, 
1S65. 



TXTEST (CHARLES), M. D., 

' * Physician to the Hospital for Sick Children, London, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. {Lately Issued ) 

The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- 
sively felt by the profession. There is probably no man living who can speak with the authority 
derived from a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
cases which have passed under his care. In the preparation of the present edition he has omitted 
much that appeared of minor importance, in order to find room for the introduction of additional 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 

Of all the English writers on the diseases of chil- I living authorities in the difficult department of med:- 
dran, there is no one so entirely satisfactory to us as | cal science in which he is most widely known.— 
Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal. 
j adicial, and have regarded him as one of the highest | 



jyY THE SAME AUTHOR. (Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 

HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon 
don, in March, 1871. In one volume small 12mo. cloth, $1 00. 



T> Y THE SAME AUTHOE. 

LECTURES ON THE DISEASES OF WOMEN. Third Americai ., 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75 i leather, $4 75. 



Henry C. Lea's Publications— (Diseases of Children). 



21 



£tMITH{J. LEWIS), M.D., 

*3 Clinical Professor of Disease* of Children in the Bellevue Hospital Med. College, N Y. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Fourth Edition, revised and enlarged. In one handsome octave volume 

of about 750 pages, with illustrations. {Nearly Ready.) 
The very marked favor with which this work hns been received wherever the English lan- 
guage is spoken, hns stimulated the author, in the preparation of the Fourth Edition, to spare 
no pains in the endeavor to render it worthy in every respect of a continuance of professional 
confidence. Many portions of the volume have been rewritten, and much new matter intro- 
duced, but by an earnest effort at condensation, the size of the work has not been materially 
increased. It is now passing rapidly through the press, and may be expected in a few days. 



pONDIE (D. FRANCIS), M.D. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely 
printed pages, cloth, $5 25 ; leather, $6 25. 

The present edition, which is the sixth, is fully up I teachers. As a whole, however, the work is the bett 
to the timesin the discussion of all those pointsin the | American one that we have, and in itsspecial adapta- 
pathology and treatment of infantile diseases which non to American practitioners u- certainly has no 
\ave been brought forward by the German *nd French 1 aqual. — New York Med. Record, ILarch 2, 1868. 



s 



UITH {EUSTACE), 31.0., 

Physician to the Northwest London Free Dispensary for Sick Childly a. 

A PRACTICAL TREATISE ON THE WASTING DISEASES OF 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) 

scribed as a practical handbook of the common dis- 
eases of children, so numerous are the affections con- 
sidered either collaterally or directly. We are 
acqnainted with no safer guide to the treatment of 
children's diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Dr. Smith's book does.— Brit. Med. Journ. , 



This is in every way an admirable book. The 
modest title which r he author has ch osen for i t scarce- 
ly conveys an adequate idea of the many s-ubjects 
upon which it treats. Wasting is *o constant an at- 
tendant upon the maladies of childhood, that a trea- 
tise upon the wasting diseases of children must neces 
sirily embrace the consideration of many affections 
of which it is a symptom ; and this is excellently well ) April 8, 1871 
done by Dr. Smith. The book might fairly h« d« 



&WAYNE {JOSEPH GRIFFITHS). 31. D., 

^-^ Physician-Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from tin Fifth and Revised 
London Edition with Additions by E. R. Hutchins, M.D. With Illustrations. In one 
neat 12mo. volume. Cloth. $1 25. (Lately Issued.) 
*** See p. 4 of this C.-italogue for the terms on which this work is offered as a premium to 
subscribers to the "American Journal of the Medical Sciences." 



CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
'to., pr, 4oO, cloth $2 ofl. 

DEvVTEES'S TREATISE ON THE DISEASES OF FE- 
MALES. With illustrations. Eleventh Edition, 
with the Author's last improvements and correc 
tions. In one octavo volume of 636 oases, with 
plates, cloth. $3 00 



MEIGS ON THE NATURE, SIGNS, AND TREAT- 
MENT OF CHILDBED FEVER 1 vol. Svo , pp. 

"*<?«> rl^Vl *<> no 

ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third Americar, 
from the Third and revised London edition. 1 vol. 
8vo., pp. 52S, cloth. $3 50. 



TJODGE {HUGH L.), M.D., 

-*■-*■ Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 
Professor Hodge's work is truly an original one I contribution to the study of women's diseases, it is of 
from beginning to end, consequently no one can pe- great value, and is abundantly able to stand on ?*■*? 
ruse its pages without learning something new. As& j own merits. — N. Y. Medical Record, Sept. 15, 1S6F. 



QlURCHILL (FLEETWOOD), M.D., M.R.I A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additiors 
by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- 
dren," <&c. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 



MONTGOMERY'S EXPOSITION OF THE SIGNS i RlGBY'S SYSTEM OF MIDWIFERY WithNct'S 
AND SYMPTOMS OF PREGNANCY. With two and Additional Illustrations. Second America a 
exquisitecolored plates, and numerous wood cuts. edition. One volume octavo cloth 422 "tu es 
In lvol.8vo.,ofnearly600pp., cloth. $3 75. | $2 50. .'• 



22 



Hsn&y C. Lea's Publications— (Diseases of Women). 



fTHOMAS {T.GAILLARD),M.D., 

Professor of Obstetrics, &c, in the College of Physicians and Surgeons, N. T., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 

800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 

The author has taken advantage of the opportunity afforded by the call for another edition of 

this work to render it worthy a continuance of the very remarkable favor with which it has been 

received. Every portion has been subjected to a conscientious revision, and no labor has been 

spared to make it a complete treatise on the most advanced condition of its important subject. 

A work which has reached a fourth edition, and is classical withoutbeing pedantic, full in thedetails 



that, too. in the short space of five years, has achieved 
a reputation which places it almost beyond the reach 
of criticism, and the favorable opinions which we have 
already expressed of the former editions seem to re- 
quire that we should do little more than announce 
this new issue. We cannot refrain from saying that, 
as a practical work, this is second to none in the Eng- 
lish, or, indeed, in any other language. The arrange- 
ment of the contents, the admirably clear manner in 
which the subject of the differential diagnosis of 
several of the diseases is handled, leave nothing to he 
desired by the practitioner who wants a thoroughly 
clinical work, one to which he can refer in difficult 
cases of doubtful diagnosis with the certainty of gain- 
ing light and instruction. Dr. Thomas is a man with a 
very clear head and decided views, and there seems to 
be nothing which he so much dislikes as hazy notions 
of diagnosis and blind routine and unreasonable thera- 
peutics. The student who will thoroughly study this 
book and test its principles by clinical observation 
certainly not be guilty of these faults.— London Lancet 
Feb. 13, 1875. 



of anatomy and pathology, without ponderous 
translation of pages of German literature, describes 
distinctly the details and difficulties of each opera- 
tion, without wearying and useless minutiae, and is 
in all respects a work worthy of confidence, justify- 
ing the high regard in which its distinguished au- 
thor is held by the profession.— Am. Supplement, 
Obstet. Journ. Oct. 1874. 



Reluctantly we are obliged to close this unsatis 
factory notice of so excellent a work, and in conclu 



Professor Thomas fairly took the Profession of the 
United States by storm when his book first made its 
appearance early in 1S68. Its reception was simply 
enthusiastic, notwithstanding a few adverse criti- 
cisms from our transatlantic brethren, the first large 
edition was rapidly exhausted, and in six months a 
second one was issued, and in two years a third one 
was announced and published, and we are now pro- 
mised the fourth. The popularity of this work was 
not ephemeral, and its success was unprecedented in 
jj] I the annals of American medical literature. Six years: 
| is a long period in medical scientific research, but 
Thomas's work on "Diseases of Women" is still the 
I leading native production of the United States. The 
I order, the matter, the absence of theoretical disputa- 
' tiveness, the fairness of statement, and the elegance 

ntire range of 



t l °lT° J llld rema J rk ,. thMt ', a ?, at ^ cher0f , gynSeC0l0gy ' of diction, preserved throughout the entir 
both didactic and clinical, Prof. Thomas has certainly the book iadicate that Professor Thomas did not 
taken the lead far ahead of his confreres, and as an , ove restimate his powers when he conceived the idea 
author he certainly has met with unusual and mer- j aud executed the work of producing a new treatise 
ited success.— Am Journ. of Obstetrics, Nov. 1874. I ap0Q disease s of women.— Prof. Pallen, in Louis- 
This volume of Prof. Thomas in its revised form 1 ville Med. Journal, Sept. 1.874. 



I?ARNES (ROBERT), M.D., F.R.C.P., 

*-* Obstetric Physician to St. Thomas's Hospital &c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In on^ handsome octavo volume, of 784 pages, with 181 illustrations. 
Cloth, «4 50 ; leather, $5 50. (Just Ready.) 
The call for a new edition of Dr. Barnes' work on the Diseases of Females has encouraged 
the author to make it even more worthy of the favor of the profession than before. By a rear- 
rangement and careful pruning space has been found for a new chapter on the Gynaecological 
Relations of the Bladder an 1 Bowel Disorders, without increasing the size of the book, while 
many new illustrations have been introdticed where experience has shown them, to be needed. It 
is therefore hoped that the volume will be found to reflect thoroughly and accurately the present 
condition of gynaecological science. 



Dr. Barnes stands at the head of his profession in 
the old country, and it requires bat scant scrutiny 
of his book to show that it has been bketched by a 
master. It is plain, practical common sense ; shows 
very deep research without being pedantic; is emi- 
nently calculated to inspire enthusiasm without in- 
culcating rashness; points out the dangers to be 
avoided as well as the success to be achieved in the 
various operations connected with this branch of 
medicine; and will do much to smooth the rugged 
path of the young gynaecologist and relieve the per- 
plexity of the man of mature years. — Canadian 
Journ. of Med. Science, Nov. 1878. 

We pity the doctor who, haviug any consider- 
able practice in diseases of women, has no copy of 
" Barnes" for daily consultation and instruction. It 
is at once a book of great learning, research, aud 
individual experience, and at the same time emi- 
nently practical. That it has been appreciated by 
the profession, both in Great Britain and in this 
country, is shown by the second edition following 
so soon upon the first. — Am. Practitioner, Nov. 
1S78. 

Dr Barnes's work is one of a practical character, 
largely illustrated from cases in his own experience, 
but by no means confined to such, as will be learned 
from the fact that he quotes from no less than 628 
medical authors in numerous couutries. Coming 
from such an author, it is not- necessary to say that 



the work is a valuable one, and should be largely 
on-ulted by the profession. — Am. Supp Obstetrical 
Journ. Gt. Britain and Ireland, Oct. 1878. 

No other gynaecological work holds a higher posi- 
tion, having become an anthority everywhere in 
diseases of women. The work has been brought 
fully abreast of present knowledge. Every practi- 
tioner of medicine should have it upon the shelves 
of his library, and the student will find it a superior 
text-book. — Cincinnati Med. News, Oct. 1S78. 

This second revised edition, of course, deserves all 
the commendation given to its predecessor, with the 
additional one that it appears to include all or nearly 
all the additions to our knowledge of its subject that 
have been made since the appearance of the first edi- 
tion The American references are, for an English 
work, especially full and appreciative, and we can 
cordially recommend the volume to American read- 
ers — Journ. of Nervous and Mental Disease, Oct. 
1878. 

This second edition of Dr. Barnes's great work 
comes to us containing many additions and improve- 
ments which bring it up to date in every feature. 
The excellences of the work are too well known to 
require enumeration, and we hazard the prophecy 
that they will for many years maintain its high po- 
sition as a standard text-book aud guide book for 
students and practitioners. — N. C. Med. Journ., 
Oct. 1878. 



Henry 0. Lea's Publications — (Diseases of Women). 23 

JjJMMET {THOMAS ADDIS), M.D. 

Surgeon to the Woman's Hospital, New York, etc. 

THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 

use of Students .and Practitioners of Medicine. In one large and very handsome octavo 
volume of nearly 900 pages, •with numerous illustrations. (Nearly Ready.) 
Dr. Emmet is so widely known as among the most eminent of those who have made gynse" 
cology a peculiar American science that the profession cannot fail to welcome a work in which 
he has condensed the results of his long and extensive experience. He has sought to consider 
the whole subject of the diseases peculiar to females in a manner which will adapt the volume, 
not only to the wants of the student as a text-book, but to those of the practitioner as an aid in 
the emergencies of daily practice A special feature of the work will be found in the numerous 
condensed tables, which convey at a glance, and within the narrowest compass, the conclusions 
to be drawn from the many thousand cases which have passed under the care of the author. 
With trifling exceptions, the illustrations are all original, and the volume will be found in every 
point of typographical execution worthy of the distinguished position which is confidently anti- 
cipated for it. 



QEADWICK [JAMES R.), A.M., M.D. 

A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one 

neat volume, royal 12tno , with illustrations. ('Preparing.') 
America has contributed so largely to the advances which have made the treatment of Dis- 
eases of Women a distinctive department of medical science, that the student will naturally 
turn to American Books for the latest and most trustworthy instruction on the subject in its 
most modern aspect. Yet there has thus far been no attempt in this country to produce a handy 
manual, presenting in a condensed and convenient form the information requisite for the learner 
or for the general practitioner. This want it has been the effort of Dr. Chadwick to supply, and 
the special attention which he has devoted to the subject is a guarantee of the value of his labors. 
A distinguishing feature of the work will be a number of diagrammatic illustrations, facilitating 
greatly the comprehension of the text. 



\yiNCKEL (F.). 

' * Professor and Director of the Gynacological Clinic in the University of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of 
the author, from the Second German Edition, by James Read Chadwick, M.D. In one 
octavo volume. Cloth, $4 00. (Lately Issued ) 
This work was writien. as the author tells us in his the field, and the present standpoint of science. The 

preface, to supply a want arising from the very brie! work has reached a second edition, and hears evidence 

consideration given to puerperal diseases hy writers oe throughout of careful study and practical experience. 

Obstetrics, in which respect it seems the profession in As its title implies, it is a manual rather than a treatise. 

his country is not different from our«. and to fill a blank — American Journal of Med. Sciences, April, IS71. 

left between the treatises upon the subject alread}' in 



rpRE OBSTETRICAL JOURNAL. [Free of postage for 1879 ) 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 

Including Midwifery, and the Diseases op Women and Infants. With an American 
Supplement, edited by J. V. Ingham, M.D. A monthly of about 96 octavo pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 

Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- 
rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. 
Collecting together the vast amount of material daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sentsto the subscriber may be estimated from the character of the gentlemen who have already 
promised their support, including such names as those of Drs. Atthill, Aveling, Robert Barnes, 
J. Henrt Bennet, Nathan Bozeman, Thomas Chambers, Fleetwood Churchill, Charles 
Clay, Johv Clay, Matthews Duncan, Arthur Farre, Robert Greenhalgh, Graily Hew- 
itt, Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Heywood Smith, 
Tyler Smith, Edward J. Tilt. Lawson Tait, Spencer Wells, &e. &c. ; in short, the repre- 
sentative men of British Obstetrics and Gynaecology. 

In order to render the Obstetrical Journal fully adequate to the wants of the American 
profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial 
charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books for re- 
view, <fec, may be addressed, to the care of the publisher. 

*** Complete sets from the beginning can no longer be furnished, but subscriptions oan com- 
mence with Vol. VI., No. 1, April, 1878, or January, 1879. 



24 



Henry C. Lea's Publications— (Midwifery). 



P 



LAYFAIR ( W. S.\, M.D., F.R.C.P., 

Professor of Obstetric Medicine in King's College, etc. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Second American, from the Second and Eevised English Edition. Edited, with Addi- 
tions, by Robert P. Harris, MD. In one handsome octavo volume of 639 pages, with 
182 illustrations. Cloth, $4 00; Leather, $5.00. (Just Ready ) 

In reprinting this work from the second London edition, the position which it has assumed 
in this country as an authoritative text-book seemed to call for such additions as would render 
it more completely suited to the wants of the American student. A careful scrutiny on the part 
of the editor has shown that but little was required for this purpose ; the work, though condensed, 
being very complete and accurate. With the exception of numerous short foot-notes, therefore, 
his additions have been confined to points in which the experience and practice of American 
obstetricians differ from those of England, and to one or two matters of recent interest. These 
are chiefly the Cesarean Section ; the varieties of forceps, and their use in the dorsal decubitus; 
dystocia from tetanoid uterine constriction; and the intra-venous injection of milk, as a substi- 
tute for the transfusion of blood. 

theory. It is the best text-book we have for students, 
a od sufficiently full of detail to suppl y all the wants 
of the practitioner. We would gladly see it in the 
hands of all who practise midwifery. — Canadian 
Journ. of Med. Set, Nov. 1878. 

Probably this is the very best and most useful 
manual of midwifery now available to the profes- 
sion. It is written in lucid, scholarly English, which 
some of our cis-Atlantic writers would do well to 
imitate. There has been no attempt to swell the 
magnitude of the work by fine writing, or by lengthy 
discussions ofobfeure poinds of which no trustworthy 
solution has yet been reached ; on the contrary, the 
tendeocy is throughout obviously towards simplic- 
ity. The chapter upon the Mechanism of Labor 
(which ought to be the crowning chapter in a trea- 
tise on obstetrics) is remarkably clear and good, and 
is divested of those features wnich in almost every 
other work we know lets only darkness instead of 
light in upon the subject. — \N. C. Med. Journ., Oct. 
1S78. 



The position which this work has so qu'ckly taken 
in this country as an authoritative text-book renters 
any extended consideration of its plan aud scope 
unnecessary. Its merits, which are many, have al- 
ready found their way to the appreciation of students 
and practitioners alike in tl e length and breadth of 
the land — Am. Supp. Ob tet. Journ. of Gt. Britain 
and Ireland, Oct 1S7S. 

This excellent text-book has been submitted to a 
thorough and careful revision, aud will be found 
fully up to the times in every department. The 
rotes by the American editor enhance the value of 
the work for the American student. Those on the 
use of forceps are pa^ticul irly g^od, and constitute 
by themselves a valuable chapter. — N. Y. M<d. 
Journ , Nov. 1S78. 

The b°st work on the subject ever published in the 
English language. It is written in a clear, pleasant 
style, without that verbjsity which characterizes 
some modern and highly pretentious works. The au- 
thor is quite up with the times, both in practice and 



TJODGE (HUGH L.), MD., 

-*■-*• Emeritus Professor of Midwifery, <vc, in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 

The work of Dr. Hodge is something more than a 
simple presentation of his particular views in the de- 
partment of Obstetrics ; it is something more than an 
ordinary treatise on midwifery ; it is, in fact, a cyclo- 
pedia of midwifery. He has aimed to embody in a 
single volume the whole science and art of Obstetrics. 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
is left unstated or unexplained— Am. Med. Times, 
Sept. 3, 1864. 

It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 

#*#= Specimens of the plates and letter-press will be forwarded to any address, free by mail 
on receipt of six cents in postage stamps. 



obstetricians. Of the American works on the subject 
it is decidedly the best. — Edinb. Med. Jour., Dec. '64. 
We have read Dr. Hodge's book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. Tho 
great attention which the author has devotad to th< 
mechanism of parturition, taken along with the coi • 
elusions at which he has arrived, point, we thin! 1 , 
conclusively to the fact that, in Britain at least, tl e 
doctrines of Naegele have been too blindly receive? 
— Gla.saow Med. Journal, Oct. 1864. 



BANNER (THOMAS H.), M.D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates andillustrations 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 



R 



AMSBOTHAM (FRANCIS H), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 



Henry C. Lea's Publications — (Midwifery, Surgery) 



25 



TEISHMAN [WILLIAM), M.I)., 

Regius Professor of Midwifery in the University of. Glasgow, &e. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the 
Philadelphia Hospital, &c. In one large and very handsome octavo volume of over 700 
pages, with about two hundred illustrations : cloth, $5; leather, $6. (Just Issiied.) 
That tliis book is recommended as a text-book by added (Dr. I\ has had unusual experience in this form 



many of the leading scholars of medicine ia this 
country, is sufficient evidence of the favoi in which 
it is held. In a word, we know of no betier book in 
our language, both for the student and practitioner. 
The value of the book is enhanced by this second 
edition, which contains many notes by our late Dr. 
Parry. — Chicago Med . Journ . and Examiner , March, 
1877. 

But the most valuable additions to the volume are 
those made by the American editor. One of the best tests 
of a man's ability is for him to take a standard work in 
our profession, like this of Dr. Leishman, and materially 
improve it. Many a one, with more ambition than wis- 
dom, has attempted it with other books and failed. But 
Dr. Parry has succeeded most admirably. We know no 
obstetrical work that has anything better on the use of 
the forceps than that which Dr. Parry has given in this, 
and no work that has the rational and intelligent views 
upon lactation with which he has enriched this. Having 
used "Leishman" for two years as a text-book for stu- 
dents, we can cordially comni end it. and ai-e quite satisfied 
to continue such use now. — Am. Practitioner, Mar. 1876. 

This new edition decidedly confirms the opinion which 
we expressed of the first edition of the work. in the May. 
1S?4, number of this Journal, that this is "the best 
modern work on the subject in the English language." 
The excellent practical notes contributed by Dr. Parry 
refer principally to the use of the forceps, lactation, and 
the puerperal diseases, and are intended to increase the 
usefulness of the work in this country. An entirely new 
chapter on diphtheria of puerperal wounds has been 



of puerperal fever), and also a number of illustrations 
of the principal obstetrical instruments in use in Ame- 
rica. We have no hesitation in saying that the work, in 
its present shape, is a great improvement on its prede- 
cessor, and in recommending it as the one obstetrical 
text- book which we should advise ever}' English speak- 
ing practitioner and student to buy. — American Jour- 
nal of Obstetrics, Feb. 1876. 

Perhaps the most useful one the student can procure. 
Some important additions have been made by the editor, 
in order to adapt the work to the profession iu this coun- 
try, and some new illustrations have been introduced, 
to represent the obstetrical instruments generally em- 
ployed in American practice. In its present form, it is 
an exceedingly valuable book for bolh the student and 
practitioner. — Nno York Med. Journal, Jan. 1876. 

Since the p> blication of Tyler Smith's lectures on 
midwifery, no text book which was iD reality the 
exponent of British practice has appeared in the 
Euglish language until Dr. Leishman supplied the 
want by his system of midwifery, which was pub- 
lished about three years ago. The chief feature in 
this woik is the exactness in description of the me- 
chanism of labor ; it exhibits most accurate obser- 
vation, and is a perfect analysis of the subject, it is 
clear, precise and masterly. The work is in every 
way a valuable addition to the works already be- 
fore the profession on the science and practice of 
obstetrics, and will, we doubt not, be the favorite 
text-book used in our schools. — Canada Med. and 
Surg. Journal, Nov. 1S76. 



pARRY [JOHN S.), M.D., 

Obstetrician to the. Philadelphia Hospital, Vice-Prest. of the Obstet Society of Philadelphia. 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 

Cloth, $1 60. {Lately Issued.) 

This work, being as near as possible a collection of the 
experiences of many persons, will afford a most useful 
guide, both in diagnosis and treatment, for this most 
interesting and fatal malady. We think it should be in 
the hands of all physicians practising midwifery. — Cin- 
cinnati Clinic, Feb. 5, 1876. 



In this work Dr. Parry has added a most valuable 
contribution to obstetricliterature. and one which meet.' 
a want long felt by those of the profession who have 
ever been called upon to deal with this cla*s of cases. — 
Boston Med. and Surg. Journ.. March 9, 1876. 



8 



T1MSON (LEWIS A.), A.M., M.B., 

Surgeon to the Presbyterian Hospital. 

A MANUAL OF OPERATIVE 

royal 12mo. volume of about 500 pages, wi 
The work before us is a well printed, profusely 
Illustrated manual of over four hundred and seventy 
pages. The novice, by a perti«al of the work, will 
gain a good idea of the general domain of operative 
surgery, while the practical surgeon has presented 
to him within a very concise and intelligible form 
the latest and most approved selections of operative 
procedure. The precision ard conciseness with which 
the different, operations are described enable the 
author to compress an immense amount of practical 
information iu a very small compass. — N. Y. Meli-.al 
Uncord, Aug. 3, 1S78 

This volume is devoted entirely t-> operative sur- 
gery, aod i- iuteuded to familiarize the studeutw.th 
the details of operations and the different modes of 



SURGERY. In one very handsome 

th 332 illustrations ; cloth, $2 50. (Now Ready.) 
I performing them. The work is handsomely illu»- 
j t rated, and thede criptions are clear and well drawn. 
| It is a clever and useful volume; every student 
should possess one The preparation of this work 
j does away with the necessity of pondering ove 
larger works on surgery for descriptions of opera- 
tion-, a^it presents in a nut-shell just what is wanted 
by the surgeon without an elaborate search to find 
it —Md. Med Journal, Aug. 1S7S. 

The author's conciseness and the repleteness of 
the work with valuable illustrations entitle it to be 
classed with the text-books for students of operative 
snrgery, and as one of reference to the practitioner. 
— Ct.nciii7t.ati Lancet and Clinic, July 27, 1S7S. 



SKEY'S OPERATIVE SURGERY. In 1 vol. 8v< 
el-., of 650 pasres ; with about 100 wood-cntf> $3 25 

COOPER'S LECTURES ON THE PRINCIPLES AND 
Practice of Surgery. Inl vol. 8vo. cloth. 750 p $2. 

GIBSON'S INSTITUTES AND PRACTICE OF SDR- 
3ERY. Eighth edition, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
iraes, about 1000 no., leaf her. raised ban dr. fcfi 5o 

THE PRINCIPLES AND PRACTICE OF SURGERY. 
By William Pirrie,F.R S.E., Professor of Surgery 
in the University of Aberdeen. Edited by John 
Neill, M.D., Professor of Surgery in the Penna. 



^ Medical College, Surgeon to the Pennsylvania Hos- 
pital, &c. In one vnry handsome octavo volume of 
780 pages, with 316 illustrations, cloth, $3 75. 
MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- 
rican, from the Third Edinburgh Edition. Tn one 
large 8vo. vol. of 700 pages, with 340 illustrations : 
cloth, $3 75. 

MILLER'S PRACTICE OF SURGERY Fourth Ame- 
rican, from the last Edinburgh Edition Revised by 
the American editor. In one large 8 vo. vol. of nearly 
700 pages, with 364 illustrations: cloth, $3 75. 



26 



Henry 0. Lea's Publications — (Surgery). 



(1B0S8 {SAMUEL D.), M.D., 

^-" Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one. fourth, notwithstanding which the price has been kept at its former very moderate 
rate. By the use of a close, though very legible type, an unusually large amount of matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, and its very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly .belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. 



We have now brought our task to a conclusion, and 
have seldom read a work wiih the practical value ol 
which we have been more impressed. Every chapter is 
so concisely put together, that the busy practiiioner. 
when in difficulty, can at once find the information he 
requires. His work, on the contrary, is cosmopolitan, 
the surgery of the world being fully represented in it. 
The work, in fact, is so historically unprejudiced, and so 
eminently practical, that it is almost a false compliment 
to say that we believe it to be destined to occupy a fore- 
most place as a work of reference, while a system of sur- 
gery like the present system of surgery is the practice of 
surgeons. The printing and binding of the work is un- 
exceptionable; indeed, it contrasts, in the latter re- 
spent, remarkably with English medical and surgical 
cloth-bound publications, which are generally so wretch- 
edly stitched as to require re-bindiug before they are 
any time in use.— Dub. Journ. of Med. Set, March, 1874. 

Dr. Gross's Surgery, a great work, has become still 
greater, both in size and merit, in its most recent form. 
The difference in actual number of pages is not more than 
130, but. the size of the page having been increa-ed to 
what we believe is technically termed ■■elephant.'' there 
has been room for considerable additions, which, toge- 
ther with the alterations, are improvements. — Land. 
Lancet, Nov. 16, 1872. 

It combines, as perfectly as possible, the qualities of 
a text-book and work of reference. We think this last, 
edition of Gros.-'s "Surgery," will confirm his title of 



' Primus inter Pares." It is learned, scholar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write so complete and faultless a 
treatise, or comprehend more solid, instructive matter 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers of mind, and the highest order of intellectual 
discipline and methodical disposition, and arrangement 
of acquired knowledge and personal experience. — N. Y. 
Med. Journ., Feb. 1873 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Journ., Oct. 1872. 

The two magnificent volumes before us afford a very 
complece view of the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first edition of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of years of experience, labor, and study, all con- 
demned upon thegreat work before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase of these two volumes of immense research — 
Cincinnati Lancet and Observer, Sept. 1&72. 

A complete system of surgery — not a mere text-book 
of operations, but a scientific account of surgical theory 
and practice in all itsdepartments. — Brit. and For. Med.' 
Chtr. Rev., Jan. 1873. 



T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 

and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
trations : cloth, $4 50. {Just Issued.) 
For reference and general information, the physician ] eases of the urinary organs. — Atlanta Med. Journ., Oct. 



or surgeon cau find no work that meets their neeessitw 
inore thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrati ns and good 
ideas, it has the unusual advantage of being easily 
comprehended, by the reasonable and practical manner 
in which the various subjects are systematized aud 
arranged We heartily recommend it to the profession 
a« a valuable addition to the important literature of dis- 



1876. 

Itis with pleasure we nowagaintakeup this old work 
in a decidedly new dress. Indeed, it must be regarded 
as a new book in very many of its parts. The chapters 
on "'Diseases of the Bladder," "Prostate Body," and 
•■Lithotomy," are splendid specimens of descriptive 
writing; while the chapter on "Stricture" is one of the 
most concise and clear that we have ever read — New 
York Med. Journ., Nov. 1876. 



T^r THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES, in 1 vol. 8vo. , with illustrations, pp. 468, cloth, $2 75. 

7)RUITT {ROBERT), M.R.C.S./frc. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eig*hth enlarged and improved London edition. Illus- 
trated with four hundred and thirty-two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 

practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every important topic. 
We nave examined the book most thoroughly, and 
cau jay that this success is well merited. His book, 
moreover, possesses the inestimable advantages of 
baving the subjects perfectly well arranged and clas- 
sified, and of being written in a style at once clear 
md succinct. — Am. Journal of Med. Sciences. 



All that the surgical student or practitioner could 
desire.— Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure. — 
Boston Med. and Surg. Journal. 

In Mr. Druitt's book, though containing only some 
seven hundred pages, both the principles and the 



Henry C. Lea's Publications— {Surgery). 



27 



J^SHHURST {JOHN, Jr.), M.D., 

Prof, of Clinical Surgery, Univ of Pa., Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Second 

edition, enlarged and revised. In one very large and handsome octavo volume of over 
1000 pages, with 542 illustrations. Cloth, $6 ; leather, $7. {Just Ready.) 
Conscientiousness and thoroughness are two very I Ashhurit's Surgery is too well known in this 
marked traits of character in the author of this : country to require special commendation from us. 
book. Out of these traits largely has grown the i This, its second edition, enlarged and thoroughly 
success of his mental fruit in the past, and the pre- | revised, brings it nearer our idea of a model text- 
sent otfer seems in no wise an exception to what has | bo >k than any recently published treatise. Though 



gone before. The general arrangement of the vol- 
ume is the 6ameas in the first edition, but every part 
has been carefully revued, and much new matter 
added.— Phila. Med. Times, Feb. 1, 1S79. 

We have previously spoken of Dr. Ashhurst's 
work in terms of praise. We wish to reiterate those 
terms here, and to add that no more satisfactory 
representation of modern surgery has yet fallen 
from the press. In point of judicial fairness, of 
power of condensation, of accuracy and conciseness 
of expres-ion. and thoroughly good Euglish, Prof. 
Ashhurst has no superior among the surgical writers 
in America.— Am. Practitioner, Jan. 1S79. 

The attempt to embrace in a volume of 1000 pages 
the whole field of surgery, general and special, 
would be a hopeless ta>k unless through the most 
tiieless industry in collating and arrangiEg, and 
the wisest judgment in condensing and excluding. 
These facilities have been abundantly employed by 



' numerous additions have been made, the size of the 
work is not materially iucreased The main trouble 
of text books of modern times is that they are too 
cumbersome. The student needs a book which will 
furnish him the most information in the shortest 
time In every respect this work of Ashhurst is 

| the model text-book- full, comprehensive and com- 
pact. — Nashville Jour, of Med. and Surg., Jan. '79. 
The favorable reception of the first edition is a 
guarantee of the popularity of this edition, which is 
fresh from the editor's hands with many enlarge- 
ments and improvements. The author of this work 
is deservedly popular as an editor und writer, and 
his contributions to the literature of surgery have 
gained for him wide reputation. The volume now 
offered the profession will add new laurels to those 
already won by previous contributions. We can 
only add that the work is well arrang< d, filled with 
practical matter, and contains in brief and clear 
laogaa^e all that is necessary to be learned by the 



the author, and he has given us a most excellent I student of surgery whilst in attendance upon lee 

treatise, brought up by the revision for the second " 

edition to the latest d-tte. Of course this book is not 

designed for specialists, but as a coui-se of general 

surgical knowledge and for general practitioners, 

and as a text-book for students it is not surpassed 

by any that has yet appeared, whether of home or 

foreign authorship. — N. Carolina Med. Journal, 

Jan. JS79. 



ures, or the general practitioner iu his daily routine 
practice. — M'l. Med. Journal, Jan. 1S79. 

The fact that this work has reached a second edi- 
tion so very soon after the publication of the first 
one, speak* more highly of its merits than anything 
we might say in the way of commendation. It 
seems to have immediately gained the favor of stu- 
dents and physicians. — Cinein. Med. News, Jan. '79. 



H 



OLMES {TIMOTHY), M.D., 

Surgeon to St George's Hospital, London. 

SURGERY, ITS PRINCIPLES 

some octavo volume of nearly 1000 pages, 
{Just Issued.) 

This is a work which has been looked for on both 
sides of the Atlantic with much interest. Mr. Holmes 
is a surgeon of large and varied experience, and one 
of the best known, and perhaps the most bdiliant 
writer upon surgical subjects in England. It is a 
book for students — and an admirable one— and for 
the busy general practitioner. It will give a student 
all the knowledge needed to pass a rigid examina- 
tion. The book fairly justifiesthe high expectations 
that were formed of it. Its style is clear and forcible, 
even brilliant at times, and the conciseness needed 
to bring it within its proper limits has not impaired 



AND PRACTICE. In one hand- 

with 411 illustrations. Cloth, $6; leather, $7. 

its force and distinctness. — N. T. Med. Record, April 
14, 1876. 
It will be found a most excellent epitome of sur- 




the trentment which is most commonly advisable. 
It will no doubt become a popular work in the pro- 
fession, and especial! 
Med. News, April, 



lv as a 
1S76. 



« — — — — " f • « 

text-book.— Cinein nat i 



TJAMILTON {FRANK H.), M.D., 

Professor of Fractures and Dislocations, &c, in Bellevue Hasp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

TIONS. Fifth edition, revised and improved. In one large and handsome octavovolurr e 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75: leather, $6 75. {Lately Issued.) 
This work is well known, abroad as well as at home, as the highest authority on its important 
subject — an authority recognized in the courts as well as in the schools and in practice — and 
again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
author has thus had the opportunity of making have enabled him to give the most careful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition. It will there- 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographical execution, and the volume is presented to the profession in the confident 
hope that it will more than maintain its very distinguished reputation. 



There is no better work on the subject in existence 
than that of Dr. Hamilton . It should be in the posses- 
sion of every general practitioner and surgeon. — Tht 
Am.Journ. of Obstetrics. Feb. 1876. 

The value of a work like this to the practical physi- 
cian and surgeon can hardly be over-estimated, and the 
necessity of having such a book revised to the latest 
d ktes, notmerely onaccouut of the practical importance 



of its teachings, but also by reason of the medico legr.l 
bearings of the cases of which it treats, and which have 
recently been the subject of useful papers by Dr. Hamil- 
ton and others, is surficiently obvious to every one The 
present volume seems to amply fill all the requisites. 
We can safely recommend it as the best of its kind in 
the English language, and not excelled in any other.— 
Journ. of Nervous and Mental Disease . J an 1876. 



28 



Henry 0. Lea's Publications— (Surgery] 



fflKICRSEN {JOHN E.), 

-*-J Professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
Seventh anc enlarged English Edition. Illustrated by eight hundred and sixty two en- 
gravings on wood. Ir two large and beautiful octavo volumes of nearly 2000 pages: 
cloth, $8 50 ; leather, $10 50. (Now Ready.) 

In revising this standard work the author has spared no pains to render it worthy of a continu- 
ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
level with the advance in the science and art of surgery made since the appearance of the 
last edition. To accomplish this has required the addition of about two hundred pages of text, 
while the illustraJtipnjS have undergone a marked improvement. A hundred and fifty additional 
wood cuts have been inserted, while about fifty other new ones have been substituted for figures 
which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
sented with the confident anticipation that it will maintain its position in the front rank of 
text-bocks for the student, arid of works of reference for the practitioner, while its exceedingly 
moderate price places it within the reach of all. 

The seventh edition is before the world as the last 
word of surgical science. There may be monographs 
which excel it npon certain points, but as a con 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners to 
read it, for it has been a p culiar province of Mr. 
Erichsen to demonstrate the absolute interdepend- 
ence of medical and surgical science We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an invaluable guide at the bedside.— Am Practi- 
tioner, April, 187S. 

It is no ille compliment to say that this is the best 
edition Mr. Erichsen has ever produced of his well- 
known book. Besides inheriting the virtues of i's 
predecessors, it possesses excellences quite its own. 
Having stated that Mr. Erichsen his incorporated 
into this edition every recent improvement in the 
science and art of surgery, it would be a supereroga- 
tion to give a detailed criticism, in short, we un- 
hesitatingly aver that we know of no other single 
work where the student and practitioner can gain at 
oncesoclear aninsight iuto the principles of surgery, 
and so complete a knowledge of the exigencies of 
surgical practice.— London Lancet, Feb. H, 1878 

For the past twenty years Ericheen's Surgery has 
maintained its place as the leading text-book, not only 
in this country, but in Great Britain. That it is able 
to hold its ground, is abundantly proven by the tho- 
roughness with which the present edition has been 
revised, and by the large amount of valuable mate- 
rial that has been added. Aside from this, < ne hun- 
dred and fifty new illustrations have been inserted, 
including quite a number of microscopical appear- 
ances of pathol) gical processes. So marked is this 
change for the better, that the work almost appears 
as an entirely new one —Wed, Reotd, Feb. 23, 1S7S 



Of the many treatises on Surgery which it has been 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as the classic 
treatise of Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, bis unsurpassed grasp 
of his subject, and vast clinical experience, qualify him 
admirably to write a mo.iel text-book. "When we wish, 
at the least cost of time, to learn the most of a topic in 
surgery, we turn, by preference, to his work. It is a 
pleasure, therefore, to see ttiat the appreciation of it is 
general, and has led to the appearance of anoiber edition. 
— Med. and, Suig. Beporter, Feb. 2, 1S78. 

Notwithstanding the increase in size, we observe that 
much old matter has been omitted. The entire work 
has been thoroughly written up, and not merely amend- 
ed by a few extra chapters A great improvement has 
been made in the illustrations. One hundred and fifty 
new ones have been added, and many of tbe old ones 
have been redrawn. The author highly appreciates the 
favor wiih which his work has been received by Ameri- 
can surgeons, and has endeavored to render his latest 
edition more than ever worthy of their approval. That 
he has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the book to 
both student and practitioner. — N. Y. Med. Journal, 
Feb. 1878. 

Erichsen has stood so prominently forward for 
years as a writer on Surgery, that his reputation is 
world wide, and his name is as familiar to the med- 
ical student as to the accomplished and experienced 
surgeon The work is not a reprint of former edi- 
tions, but has in many places been entirely rewrit- 
ten. Keceut improvements in surgery have not es- 
caped his notice, various new operations have been 
thoroughly analyzed, and their merits thoroughly 
diocussed One hundred and fifty new wood-cuts 
add to the value of this work. — N U. Med. and Surg. 
Journal, March, 187S. 



flOSSELlN (L.), 

\JT Professor of dtinicl Surgery in the Faculty of Medicine, Paris, etc. 

CLINICAL LECTURES ON SURGERY. Delivered at the Hospital of 

La Charite. Translated from the French by Lkwis A. Stimson, M.D., Surgeon to the 
Presbyterian Hospital, New York. With illustrations. In one neat octavo volume of 
350 pages ; cloth, $2 50. (Now Ready.) From the Medical News and Library. 

SUM3IAJRT OF CONTENTS. 

PARTI Surotcal Diseases of Youth. 8 Lect. PART IV. Traumatic Fever, Septicemia, 

" II Fractures of the Limbs. 18 " and Pyemia. 4 Lect. 

" III. Traumatic Osteitis and Necrosis 2 " PART V. Diseases of the Articulations. 7 " 

" VI. Phi, egmon, Abscess, and Fistula. 3 " 

It will be seen from this brief abstract of the contents that these Lectures treat of subjects 
which are of daily interest to the practitioner, while some of them hardly receive in the text- 
books the attention which t'-eir importance deserves. 



ASHTON ON THE DISEASES, INJURIES, AND MAL- 
FORMATIONS OF THE RECTUM AND ANUS; with 
remarks on Habitual Constipation. Second Ameri- 
can, from the fourth and enlarged London Edition. 
With illustrations. In one 8vo. vol. of 287 pages, 
cloth, $3 25. 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, with 
an additiooal chapter on Military Surgery. One 
12mo. vol. ol db'i pa.£?>s, with 18* wood-cuts. Cloth, 
$1 75. 



Henry C. Lea's Publications— *(Oph thalmology). 29 

jQRYANT {THOMAS), F.R.C.S., 

•*-* Surgeon to Guy's Hospital. 

THE PRACTICE OF SURGERY. Second American, from the Sec- 

ond and Revised English Edition. With Six Hundred and Seventy-two Engravings on 
Wood. In one large and very handsome imperial octavo volume of over 1000 large and 
closely printed pages. Cloth, $6; leather, $7. (Just Ready.) 
This work has enjoyed the advantage of two thorough revisions at the hand of the author since 
the appearance of the first American edition, resulting in a very notable enlargement of size and 
improvement of matter. In England this has led to the division of the work into two volumes, ' 
which are here comprised in one, the size being increased to a large imperial octavo, printed on 
a condensed but clear type. The series of illustrations has undergone a like revision, and will 
be found correspondingly impro\ed. 

The marked success of the work on both sides of the Atlantic shows that the author has suc- 
ceeded in the effort to give to student and practitioner a sound and trustworthy guide in the 
practice of Surgery; while the simultaneous appearance of the present edition in England and 
in this country affords to the American reader the benefit of the most recent advances made 
abroad in surgical science. 

DROWNE [EDGAR A.), 

Suraeon to the. Liverpool Eye and B<»r Infirmary, and to the Dispensary for Skin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structions in Ophthalmoscopy, arranged for the Use of Students. With thirty-fiveillustra • 
tions. In one small volume royal 12mo. of 120 pages: cloth, $1. (Now Ready.) 
This capital little work should be in the hands of | strument and the suggestions to aid in interpreting 
ev ry medical student, and we had almostsaid every what is seen. — Detroit Wed. Journ., Nov. 1877. 



general practitioner. Its explanation of the optic. il 
principles on which the ophthalmoscope is founded, 
is so clear and simple that the most stupid reader 
could scarcely fail of understanding them. Equally 
satisfactory are the directions for the use of the in- 



The information is given in a very concise, but we may 
also add, in a verv clear and forcible manner. Many oi 
the diagrams that illustrate the text are original and 
ingenious in their construction, and very instructive. — 
Ed in. Med. Journ. 



flARTER [R. BRUDENELL), F.R.CS., 

{-S Ophthalmic Surgeon to St. George s Hospital, ttc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 

ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just 
Iss7ied.) 

Dr. Green, whose reputation and experience in this department are well known, has given this 
work a very careful revision, and has introduced much matter which will be found of importance 
to the practitioner As his system of test types is the one recommetded by the author, they 
have been inserted in the volume in a shape which will admit of their being detached and 
mounted for convenient office use. 

These test-types, on a sheet for mounting, can be had separate, price 25 cents. 

It would be difficult for Mr. Caner to write an unin- . in view, and presents the subject in a clear and concise 
structive book, and impossible for him to write an un- I manner, easy of comprehension, and hence the more 
interesting one. Even on subjects with which he is not | valuable. VVe would especially commend, however, as 
bound to be familiar, he can discourse with araredegree j worthy of high praise, the manner iii which the thera- 
of clearness and effect. Our readers will therefore not | peutics of disease of the eve is elaborated, for here the 
be surprised to learn that a work by him on the Diseases author i.-. particularly clear and practical, where other 
of the Eye makes a very valuable addition to ophthal- j writers are unfortunately too ofien deficient. The final 
mic literature. . . . The book will remain one useful | chapter is devoted to a discus>ion ot the rises and selec- 
alike to the general and the special practitioner. Not ' tion of spectacles, and is admirably compact, plain, and 



the least valuable result which we expectfrom it is that 
it will to some considerable extent despecialize this bril- 
liant department of medicine. — London Lancet, Oct. 30, 
1875. 

It is with great pleasure that we can endorse ihe work 
as a most valuable contribution to practical ophthal- 
mology. Mr. Carter never deviates from the end he has 



useful, especially the paragraphs on the treatment of 
presbyopia and myopia. In conclusion, our thanks are 
due the author for many useful hiuts in the great sub- 
ject of ophthalmic surgery and therapeutics, a field 
where of late years we glean but a few grains of sound 
wheat from a mass of chaff — New York Medical Recmd, 
Oct. 23, 1875. 



L 



IKTELLS {J. SOELBERG), 

" ' Professor of Ophthalmology in King's College Hospital, &c. 

A TREATISE ON DISEASES OF THE EYE. Third American, 

from the Fourth and Revised London Edition, with additions ; illustrated with numerous 
engravings on wood, and six colored plates Together with selections from the Test-types 
of Jaeger and Snellen. In one large and very handsome octavo volume. (Preparing.) 

AURENGE {JOHNZ.), F.R.G.S., 

Editor of the Ophthalmic Review, &c. 

A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In 
one very handsome octavo volume, cloth, $2 75. 

' AWSON {GEORGE), FR.GS. Engl., 

* Assistant Surgeon to the Royal London Ophthalmic Hospital Moorfields, &c . 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, cloth, $3 50. 



30 



Henry C. Lea's Publications— -{Medical Jurisprudence). 



~DURNETT {CHARLES H.) t M.A , M.D., 

•*-* Aural Surg to the Presb. Hasp., Surgeon-in-char ge of thf > In fir for Bis. of the Ear, Phil a. 

THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, 
$5 50. (Just Ready.) 

Recent progress in the investigation of the structures of the ear, and advances made in the 
modes of treating its diseases, would seem to render desirable a new woik in which all the re- 
sources of the most advanced science should be plaeed a+ the disposal of the practitioner. This 
it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in 
the special study of the subject are a guarantee that the result of his labors will prove of service 
to the profession at large, as well as to the specialist in this department. 

On account of the great advances which have been 
made of late years in otology, and of the increased 
interest manifested in it, the medical profession will 
welcome this new work, which presents clearly aDd 
concisely its present aspect, whilst clearly indi- 



cating the direction in which further researches can 
be most profitably carried on. Br. Barn> tt from his 
own matured experience, and availing himself of 
the observations and discoveries of others, has pro- 
duced a work, which as a text-book, stands facile 
princeps in our language. We had marked several 
passages as well worthy of quotation and the atten- 
tion of the general practitioner, but their number and 
the space at our command forbid. Perhaps it is bet- 
ter, as the book ought to be in the hands of every 
medical student, and its study will well repay the 
busy practitioner in the pleasure he will derive from 
the agreeable style in which many otherwise dry 
and mostly unknown subjects are treated. To the 
specialist the work is of the highest value, and his 

sense of gratitude to Dr. Burnett will we hope, be l^Tn^m^ iVngaag^and Vpe^ S 
proportionate to the amount ot benefit he can obtain the J care aud Btte £ ioil he L4iVen to th "scientific 
trom the careful study ot the book, and a constant ' 
reference to its trustworthy pages. — Edinbu gh 
Med. Jour., Aug. 1S78. 



As the title of the work indicates, this volume 
treats of the anatomy and physiology of the ear, as 
well as. of its diseases, and the author has taken 
special pains to make thisdifficult and complicated 
matter thoroughly clear and intelligible. The book 
is designed especially for the use of .-tudents and 
general practitioners, and places at their disposal 
much valuable material. Such a book as the pre- 
sent one, we think, has long been needed, aud we 
may congratulate the author on his success in fill- 
ing the gap. Both student and practitioner can 
study the work with a great deal of benefit. It is 
profusely and beautifully illustrated.— N. Y. Hos- 
pital Gazette, Oct 15, 1817. 

The appearance of this book is another proof of the 
rapidly increasing amount of honest, valuable work 
that is now 1 eiug done in the various branches of 
medical scienceiu this country. Dr. Burnett is to be 
commended for having written the best book on the 



side of the subject.— N. Y. Med. Journ., Dec. 1S77. 



/TAYLOR (ALFRED S.), M. D., 

-*• Lecturer on Med. Jurisp. and Chemistry in Guy' s Hospital . 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Just Issued.) 
The present is based upou the two previous edi- 
tions ; "but the complete revision rendered necessary 
by time has converted it into a new work." This 
statement from the preface contains all that it is de- 
sired to know in reference to the new edition The 
works of this author are already in the library of 
every physician who is liable to be called upon for 
medico-legal testimony (and what > neis not?), so that 
all that is required to be known about the present 
book is that the author has kept it abreast with the 
times What makes it now, as always, especially 
valuable to the practitioner is its conciseness and 
practical character, only those poisonous substances 

JDY THE SAME AUTHOR. 

MEDICAL JURISPRUDENCE. 

by John J. Reese, M.D., Prcf. of Med 
octavo volume of nearly 900 pages. Clo 

To the members of the legal and medical profession, 
it is unnecessary to say anything commendatory of 
Taylor's Medical Jurisprudence. We might as well 
undertake to speak of the merit of Chitty's Plead- 
ings. — Chicago Legal News, Oct. 16, 1S73. 

It is beyond question the most attractive as well 
as most reliable manual of medical jurisprudence 
published in the English language. — Am. Journal 
of Syphilography, Oct. 1S73. 

It is altogether superfluous for us to offer anything 
in behalf of a work on medical jurisprudence by an 
author who is almost universally esteemed to be the 

ny THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00; leather, $12 00 
This great work is now recognized in England as the fullest and most authoritative treatise on 
e7ery department of its important subject. In laying it, in its improved form, before the Ameri- 
cm profession, the publisher trusts that it will assume the same position in this country. 



being described which give rise to ldgai investiga- 
tions.— 2Vie Clinic, .Nov. 6, 1S75. 

Dr. Taylor has brought to bear on the compilation 
of this volume, stores of learning, experience, and 
practical acquaintance with his subject, probably far 
beyond what any other living authority on toxicol- 
ogy could have amassed or utilized. He has fully 
sustained his reputation by the consummate skill 
aud legal acumen he has displayed in the arrange- 
ment of tlie subject-matter, aud the result is a work 
on Poisons which will be indispensable to every stu- 
dent or practitioner in law and medicine. — The Dub- 
lin Journ. if Med So ., Oct. lS7f>. 



Seventh American Edition. Edited 

. Jurisp. in the Univ. of Penn. In one large 
th, $5 00; leather, $6 00. (Lately Is sited.) 
best authority on this specialty in our language. On 
this point, however, we will say that we consider Dr. 
Taylor to be the safest medico-legal authority to fol- 
low, in general, with which we are acquainted in any 
language. — Va. Clin. Record, Nov. 1S73. 

This las I edition of the Manual is probably the best 
of all, as it contains more material and is worked up 
to the latest views of the author as expressed in the 
last edition of the Principles. Dr. Reese, the editor 
of the Manual, has done everything to make his 
work acceptable to his medical countrymen. — N. Y. 
Mad. Record, Jan. 15, 1874. 



Henry 0. Lea's Publications— (ilfts^ZfoHeot/s). 31 



R 



WHO MP SON [SIR HENRY), 

•*- Surgeon and Professor of Clinical Surgery to University College Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. {Just Issued.) 
JOY THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHKA AND URINARY FISTULJE. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
( Lately Published.) 

OBERTS ( WILLIAM), M.D.. 

Lecturer on Medicine in the Manchester School of Medicine etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. -In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
Published.) 

rPUKE {DANIEL HACK), M.D , 

■* Joint author of " The Manual of Psychological Medicine" &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, c.oth, $3 25. {Lately Issued.) 

J>LANDFORD [G. FIELDING), M.D., F.R.C.P., 

«*-^ Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment^ 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the* 

United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 

handsome octavo volume of 471 pages; cloth, $3 25. 

It satisfies a want which must have been sorely actually seen in practice and the appropriate treat - 

fjlt by the busy general practitioners of this country, aient tor them, we find in Dr. Bland ford's, work a 

it takes the form of a manual of clinical description considerable advance over previous writings on ihe 

of the various forms of insanity, with a description subject. His pictures of the various forms of mental 

of the mode of examiuing persons suspected of in- , iisease are so clear and good that no reader can fail 

sanity. We call particular attention to this feature i ;o be struck with their superiority to those given in 

of the book, as giving it a unique value to the gene- i ordinary manuals in the English language or (so far 

ral practitioner, if we pass from theoretical cunside-' as our own reading extends; in any other. — London 

ririons to descriptions of the varieties of insanity as I Practitioner, Ftb 1871. 



f EA [HENRY C). 

SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL. AND TORTURE. Third Revised 

and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 

$2 50. {Just Ready) 

The appearance of a new edition of Mr. Henry C. , polemic. Though he obviously feels and thinks 

Lea s "superstition and Force" is a s gn that our j strongly, he succeeds in attaining impartiality. 

highest scholarship is not without honor in its na- i Wheti er looked on as a picture or a mirror, a work 

ti-e country. Mr. Lea has met every fresh demand \ such as this has a lasting value. — Lippincotfs 

for his work with a careful revision of it, and the j Magazine, Oct. 1S7S. 

present edition is not only fuller and, if possible, | Mr Lea , g carious historical monographs, of which 
more accurate than either of the preceding, but, i oue ,, f lhe mQSC uaportaQt is here reproduced in au 
from the thorough elaboration, is more like a har- enlarged form, have given him an unique position 
monious concert and less like a baton ot studies.— , amoag E , glish aad American scholars, de is dis- 
The Nation, Aug. 1, 1878. . t i Dgu i..,h e( i f or his recondite and affluent learning, 

Many will be tempted to say that this, like the ' his power of exhiustive historical analysis, the- 
' DeclineandFall,"isoneof the uncriiicizable books ■ breadth and accuracy of his researches amoDg the 
Its facts are innumerable, its deductions simple and | rarer sources of knowledge, the gravity and temper- 
inevitable, and its cht.vauoo-de-frise of references | ance of his statements, combined with singular 
bristling and dense enough to make the keenest, ! earnestness of conviction, aud his warm attachment 
stoutest, and best equipped assailant think twice | to the cau-e of human freedom and intellectual pro- 
before advancing. Xor is there anything contro- I gress. — N. Y. Tribune, Aug. 9, 1878. 
versial in it to provoke assault. The author is no 



73 F THE SAME AUTHOR. {Late y Published.) 

STUDIES IN CHURCH HISTORY—THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OE CLERGY— EXCOMMUNICATION. In one large royal 
12mo. volume of 516 pp.; cloth, $2 75. 

The story was never told more calmly or with ias a peculiar importance for the English student, and 
greater learning or wiser thought. We doubt, indeed, ' • s a chapter on Ancient Law likely to be regarded as 
If any other study of this field can be compared with | inal. We caD hardly pass from our mention of such 
this for clearness, accuracy, and power. — Chicago \ yorks as these — with which that on "Sacerdotal 
Examiner, Dec. 1870. I lol'.hacv" should be included — without Doting the 

Mr. Lea's latest work, "Studies in Church History," j literary phenomenon that the head of one of the first 
fully sustains the promise of the first. It deals with ; American houses is also the writer of some of its most 
three subjects — the Temporal Power. Benefit of | original books. — London Aihenmum, Jan. 7, 1571. 
Clergy, and Excommunication, the record of which | 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE. 



A. jiedcan Journal of the Medical Sciences 

Abstract, Monthly, of the Med. Sciencet 

Allen's Anatomy 

Anatomical Atlas, by Smith and Horner 

Ashton on the Rectum and Anus 

Attneid's Chemistry 

Ashwell on Diseases of Females 

* is lihurst's Surgery 

Browne on Ophthalmoscope . 

Browne on the Throat 

Burnett on the Ear . 

Barnes on Diseases of Women 

Bellamy's Surgical Anatomy 

*Bryant's Practical Surgery . 

Bloxani's Chemistry 

Blandford on Insanity . 

Basham on Renal Diseases . 

Brinton on the Stomach 

Barlow's Practice oi Medicine 

Bowman's (John E.) Practical Chemistry 

Bowman's (John E.) Medical Chemistry 

*Bristowe*s Practice .... 

Buinstead on Venereal .... 

8 u instead and Cullerier's Atlasof Venereal 

^Carpenter's Human Physiology 

Carpenter on the Use and Abuse of Alcohol 

Cornil and Ranvier .... 

Carter on the Eye 

Cleland's Dissector .... 

Classen's Chemistry .... 

Clowes' Chemistry 

Century of American Medicine 
Cbadwiek on Diseases of Women . 
Charcot on the Nervous System 
Chambers on Diet and Regimen . 
Chambers's Restorative Medicine 
Christison and Griffith's Dispensatory 
Churchill's Svstem of Midwifery . 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery . 

* Jullerier's Atlas of Venereal Diseases 
Cyclopaedia of Practical Medicine 
Dalton's Human Physiology 
Davis's Clinical Lectures 
Dewees on Diseases of Females . 
Druitt's Modern Surgery 
*Dunglison's Medical Dictionary . 
Ounglison's Human Physiology . 
Ellis's Demonstrations in Anatomy 
Erichseh's System of Surgery 
Emmet on Diseases of Womeu 
Farquharson's Therapeutics . i 
Fenwick's Diagnosis .... 
Finlayson's Clinical Diagnosis 
Flint on Respiratory Organs . 
Flint on the Heart 

* Flint's Practice of Medicine. 
Flint's Essays . : . . . 
Flint on Phthisis . . 
Flint on Percussion .... 
Fothergill's Handbook "of Treatment . 
Fothergiil's Antagonism of Tnerapeutic Agents . 
Fownes's Elementary Chemistry . 

Fox on Diseases of the Skin . • 

Fuller on the Lungs. &c. . 

Green's Pathology and Morbid Anatomy . 

Gibson's Surgery' 

Gluge's Pathological Histology, by Leidy . 

* Jray's Anatomy 

Galloway's Analysis 

iariffith's (R. E.) Universal Formulary 

Gross on Urinary Organs 

Gross on Foreign Bodies in Air-Passages 

* Jross's Principles and Practice of Surgery 
Gosseliu's Clinical Lectures on Suigery 

Habershon on the Abdomen 

Hamilton on Dislocations and Fractures 
Bartshorne's Essentials of Medicine . 
Hartshome's Conspectus of the Medical Sciences 
Hartshorne's Anatomy and Physiology 
Hamilton on Nervous Diseases . 

Heath's Practical Anatomy 

Hoblyn's Medical Dictionary .... 



PAGE 

. 1 




*Iodge'8 Obstetrics 

lolland's Medical Notes and Reflections 
Holmes's Surgery .... 
Holden : s Landmarks 
lorner's Anatomy and Histology 
Hudson on Fever .... 
Jill on Venereal Diseases 
Iillier's Handbook of Skin Diseases 
Tones (C. Handheld) on Nervous Disordei 
Kirkes' Physiology .... 
j Knapp's Chemical Technology 
Lea's Superstition and Force 
Lea's Studies in Church History . 

Lee on Syphilis 

Lincoln on Electro-Therapeutics . 
Leishman's Midwifery .... 
La Roche on Yellow Fever . 
La Roche on Pneumonia, &c. 
Laurence and Moon's Ophthalmic Surgery 
Lawson on the Eye .... 

Lehmann's Physiological Chemistry, 2 vol 
Lehmann's Chemical Physiology . 
Ludlow's Manual of Examinations 

Lyons on Fever 

Medical News and Library . 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . 

Neill and Smith's Compendium of Med. Sci 

Neligan's Atlas of Diseases of the Skin 

Obstetrical Journal 

Parry on Extra-Uterine Pregnancy 

Pavy on Digestion .... 

Pavy on Food 

Parrish's Practical Pharmacy 
Pirrie's System of Surgery . 
Playfair's Midwifery .... 
Quain and Sharpey's Anatomy, by Leidy 
Roberts on Urinary Diseases . 
Ramsbotham on Parturition . 
Remsen'a Principles of Chemistry 

Rigby's Midwifery 

Rodwell's Dictionary of Science . 

S.imson's Operative Surgery 

Swayne's Obstetric Aphorisms 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Schiifer'8 Histology 

Smith (J. L.) on Children 

Smith (H. H.) and Horner's Anatomical Atla 

Smith (Edward) on Consumption . 

Smith on Wasting Diseases in Children 

Still^'s Therapeutics .... 

*Stille & Maisch's Dispensatory . 

Stnrges on Clinical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicine . 

Tanner on Pregnancy .... 

Taylor's Medical Jurisprudence . 

Taylor's Principles and Practice of Med J 

Taylor on Poisons ..... 

Tuke on the Influence of the Mind 

Thomas on Diseases of Females . 

Thompson on Urinary Organs 

Thompson on Stricture . 

Todd on Acute Diseases . 

Woodbury's Practice 

Walshe on the Heart 

Watson's Practice of Physic 

Wells on the Eye . 

West on Diseases of Females 

West on Diseases of Children 

West on Nervous Disorders of Children 

What to Observe in Medical Cases 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson on Diseases of the Skin 

Wilson's Plates on Diseases of the Skin 

Wilson's Handbook of Cutaneous Medicine 

Wohler's Organic Chemistry 

Winckel on Childbed 



Hodge on Women 

J0f Books marked with * exceed the limit 
are therefore not mailable. Patties desiring them will therefore pleate to give instiu 
to forwarding. 



of Four Pounds allowed by the Post-office, and 

tions as 



18 p 



PAGE 

24 



^ '; 



